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! 



PRACTICAL PROBLEMS 



OF 



DIET AND NUTRITION 



MAX EINHORN, M.D. 

Professor of Medicine at the New York Postgraduate Medical School 

and Hospital and Visiting Physician to the German 

Hospital, New York. 



NEW YORK 

WILLIAM WOOD AND COMPANY 

MDCCCCY 



LIBRARY of C 


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rteceiveu 


Two Copies 


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COPYRIGHT, 1905, 
BY WILLIAM WOOD AND COMPANY. 



2>4- 



PREFACE. 

The knowledge of nutrition and diet should be the ABC 
of the physiologist and physician. Without it no rational 
treatment of any disease is possible. With a full understand- 
ing of it many states of invalidism can be greatly amelio- 
rated or completely cured. 

On several occasions I have written papers dealing with 
important questions relating to diet. In these, some general 
known principles in connection with experience of my own of 
practical value have been discussed in detail. In all of them 
special stress ivas laid upon the great importance of sufficient 
nutrition. 

Feeling convinced that these papers on diet will be of ma- 
terial aid to the practitioner in the treatment of disease — and 
appreciating also that such articles, even if once read in the 
medical journals, are quickly forgotten— I have decided to col- 
lect them in the form of a monograph. It is my sincere hope 
that this booklet will prove of some service to the medical pro- 
fession in promulgating the paramount importance of a suf- 
ficient nutrition. 

Max Einhoen. 
New York, March, 1905. 



CONTENTS 



i. 



The Art of Eating Properly (Euphagia) and the Harm of Eating 
too Rapidly and too Slowly (Tachyphagia and Brady- 



phagia), 






1 


Euphagia, 






2 


Tachyphagia, 






. 3 


Bradyphagia, 






. 4 


Treatment of Faulty Eating, 






6 


II. 


Dietetics in Diseases of the Stomach and Intestines, . . .8 


General Rules, 






8 


Diet in Health, 






11 


Composition of Food Substances, . 






13 


Diet Scales, 






15 


Dietetics in Acute Diseases of the Stomach, . 






18 


Ulcer of Stomach, 






18 


Dietetics in Chronic Affections of the Stomach, 






19 


Diet in Organic Lesions, ..... 






20 


Diet in Functional Disturbances, 






21 


Diet in Subacidity, 






24 


Diet in Superacidity, ..... 






25 


Diet in Achylia Gastrica, .... 






25 


Diet in Diseases of the Intestines, . 






26 


III. 


Diet of Dyspeptics, ......... 28 


Sitophobia 28 


Illustrative Cases, . . . . . . . . .31 


Treatment of Inanition, .... 






33 



VI 



CONTENTS. 



IV. 

PAGE 

Sitophobia of Enteric Origin 36 

Illustrative Cases 37 

Remarks, 40 

Treatment 42 



V. 

Sitophobia and Inanition, and Their Treatment, . . . .43 

Definition of Sitophobia, 44 

Definition of Inanition, 45 

Illustrative Cases, 48 

Treatment, 51 



VI. 



The Art of Increasing and Diminishing the Bodily 


Weight at 


Will, 


Revenues and Expenditures of the Body, 




. 55 


Body Equilibrium, .... 




. 55 


Work and Rest, 




. 56 


Leanness, ...... 




. 58 


Increasing Bodily Weight, 




. 59 


Reducing Bodily Weight, 




. 60 



PRACTICAL PROBLEMS 

OF 

DIET AND NUTRITION. 



i. 

THE AET OF EATING PEOPEELY (EUPHAGIA) 

AND THE HAEM OF EATING TOO EAP- 

IDLY AND TOO SLOWLY (TACHY- 

PHAGIA AND BEADYPHAGIA). 1 

Eating or partaking of food is our principal means 
of sustaining life. Without this the organism cannot 
thrive, cannot gain in weight (grow), and can exist only 
a short while. During the time of total abstinence the 
body lives on its own substance, steadily losing in 
weight, and soon dies. It will therefore not be out of 
place to devote our attention to this subject. 

In the animal kingdom, as well as also among uncivil- 
ized peoples, the obtaining and taking of food forms the 
principal occupation during life. The necessity of ob- 
taining food has remained the same with civilized man, 
but the manner of partaking of it has been changed par- 
tially to his disadvantage. New interests have arisen, 
and the act of eating has been partially relegated to the 
background. Many busy persons scarcely take time to 
eat ; they swallow hastily any kind of food without spe- 
1 M. Einhorn: Medical Record, January 7th, 1905. 



2 DIET AXD KTTTBITTOE". 

cial selection, at times poorly prepared. The natural 
consequence of this is that under these conditions 
diseases of the digestive system develop quite fre- 
quently. 

I may be permitted to describe first in a few words the 
art of eating properly (euphagia), and then discuss two 
improper modes of eating (tachyphagia and bradypha- 
gia). 

Euphagia. — Like all natural processes, the partaking 
of food, if done in a correct manner, affords the body 
pleasure and satisfaction. For this purpose, however, 
the organism must be prepared by previous work and 
subsequent rest. Already in the Bible the following 
statement is found : "In the sweat of thy brow shalt thou 
eat bread." This shows the importance of work on eat- 
ing. A similar proverb exists in the German language, 
"Arbeit macht das Leben suss" (Work sweetens life), 
which sentence naturally refers not only to eating, but 
to all functions of life. Granted, however, that work is 
necessary, yet it must not be in excess or lead to exhaus- 
tion, as in this condition the appetite usually disappears 
and digestion becomes sluggish. 

Meals are best taken during those periods when the 
body is at rest. The time for taking food must not be too 
short. During the meal it is better not to think of busi- 
ness, or serious or perhaps even sad things. Our whole 
and undivided attention should be given to our meals. 
Pleasant company, light conversation, jokes, and stories 
add to the enjoyment of food. 

It is generally known what a powerful influence the 
brain exerts over our digestive faculties. Great grief 
robs us of our appetite and may cause real disturbances 
of digestion. Pawlow has lately established the physio- 
logical importance of the mental state on digestion, hav- 



AET OF EATIXG. 3 

ing shown, for instance, that delicacies produce secre- 
tion of gastric juice as soon as they are perceived by the 
eye, even before they are eaten. 

The food must not only be palatable, but must be 
served in an attractive manner (fine dishes, table decora- 
tions, etc.). 

In eating we must take time to chew our food thor- 
oughly. This serves a double purpose: (1) through the 
act of mastication the coarser particles of food are bro- 
ken up ; (2) more saliva is secreted and is thoroughly 
mixed with the food. The digestion of starch is thus 
materially aided, and the proteids are made more easily 
accessible to the action of the gastric juice. 

Water should accompany each meal. It increases the 
appetite and the enjoyment of food. It also serves a 
useful purpose when substances are taken into the 
mouth or even swallowed too hot. A mouthful of cold 
water will at once lower the temperature and obviate any 
danger of burning. 

After eating we should rest a little while before re- 
turning to our work. 

Tachyphagia, or hasty eating, is a common evil. The 
food is only half masticated, or not at all, and enters the 
stomach without being properly insalivated and commi- 
nuted. It is easily seen that thus the foundation for 
many a stomach or bowel ailment is laid. The coarse 
food causes too much irritation to the gastric mucous 
membrane, and it is not sufficiently acted upon by the 
gastric juice, which usually only affects the external sur- 
face, leaving the rest unchanged. This refers particu- 
larly to the digestion of albuminoids. Starch, however, 
under these conditions is also left without any alteration, 
because the ptyalin of the saliva is not present in suffi- 
cient quantity. The chyme, therefore, reaches the bowel 



4 DIET AND NUTRITION. 

practically unchanged, causing here almost a state of 
irritation. Besides the mechanical effect, however, 
tachyphagia has other drawbacks, because it encourages 
the taking of large quantities of food in too short a time, 
and the consumption of foods too hot or too cold. In 
eating correctly a prdeovision is ma that not too much 
food passes into the stomach at once, for mastication re- 
quires time ; besides there is some time spent in conver- 
sation and in serving the different courses. The tem- 
perature of food and drink is partially equalized by the 
slow passage through the mouth and oesophagus. All 
these factors are absent in eating too rapidly, and we 
thus have the two obnoxious points spoken of above, 
viz., unsuitable quantity of food and unsuitable temper- 
ature — two conditions that often cause digestive disturb- 
ances. 

Clinically the disadvantages of tachyphagia are so 
well known that it does not seem necessary to illustrate 
them by means of examples. Every physician has ob- 
served cases of gastric and intestinal catarrh, hyperchlor- 
hydria, and other tedious digestive disturbances, the eti- 
ological factors of which could be found in the existing 
tachyphagia. 

Bradyphagia. — By bradyphagia (eating too slowly) 
we understand a condition in which eating is performed 
abnormally slowly, so that the organism is thereby in- 
jured. 

In general, we as physicians will more often have to 
battle against the above -described tachyphagia, advocat- 
ing a properly slow or, more correctly, a rational mode 
of eating. This, however, may be, and is, indeed, over- 
done by some persons to their detriment. In such cases 
every morsel is masticated and remasticated, and before 
being swallowed is again chewed and everything carefully 



AKT OF EATING. 5 

tested with the tongue, whether it has been thoroughly 
comminuted. An abnormal fear and suspicion develop 
in this manner, and for such a person eating is a difficult 
task. The enjoyment and pleasure of eating are trans- 
formed into a doleful process, and thus frequently a 
smaller quantity of food is taken than usual. Not rarely 
it happens that the bolus occasionally remains in the 
pharynx or oesophagus and refuses to budge. It is not 
an organic affection that causes this variety of dyspha- 
gia, but merely the excitement and fear of eating. In 
these cases, in course of time, a chronic inanition devel- 
ops, owing to bradyphagia and the added temporary dys- 
phagia, in consequence of which the patient gradually 
becomes weaker and occasionally dies, unless we combat 
the evil energetically at once. 

Since bradyphagia is of comparatively rare occurrence, 
I do not hesitate to give a few examples. 

Case I.— April 2d, 1896. G. I. L., 32 years old, law- 
yer, has suffered for the last five or six years from diges- 
tive disturbances. He has lost considerable flesh, and 
has been unable for the last three years to attend to busi- 
ness. He complains of his inability to swallow food and 
of intense pains in the upper abdominal region, particu- 
larly after meals. He has lost in all about forty pounds, 
of which the smallest quantity in proportion was lost 
during the last six months. He adheres to a strict diet 
and eats very slowly, taking a half -hour to consume a 
glass of milk. 

Status praesens : The whole body is emaciated ; exam- 
ination of the thoracic organs gives negative results ; the 
stomach extends to about two fingers' width below the 
navel. The epigastrium is slightly sensitive to pressure. 
One hour after test breakfast the stomach contents showed 
the presence of free HC1 and an acidity of 78. The swal- 



6 DIET AND NUTBITION. 

lowing sound occurred seven seconds after the drinking 
of water. 

In the absence of any organic lesion the diagnosis of 
neurasthenia and hyperchlorhydria was made. The dif- 
ficulty in eating was explained by the psychic excite- 
ment subsequent to the sitophobia and bradyphagia. 
The patient was put upon a more liberal diet and advised 
to eat more quickly. In three weeks he gained eleven 
pounds ; he continued to gain in weight and recovered 
entirely. 

Case II.— March 23d, 1903. Mrs. E. F., about 35 
years old, has been suffering from digestive disturbances 
for the last three years. She claims to have pains in the 
epigastrium after every meal, and suffers much from 
belching, constipation, and lack of sleep. She is much 
run down and has been unable for the last two years to 
look after her household duties. She says that she eats 
only the lightest foods (principally liquid diet) with the 
greatest care, requiring twenty minutes for the ingestion 
of half a plate of soup and twenty-five minutes for a cup 
of milk. Owing to these extreme precautions, she is 
obliged to take her meals alone. She is surprised that 
in spite of all this she does not improve. The diagnosis 
of neurasthenia, hy{)er8esthesia of the stomach, and bra- 
dyphagia was made. The patient was told to eat a vari- 
ety of plain and simple foods, and to eat and drink more 
rapidly. In two or three months she had completely re- 
covered. She ate with the rest of the family and was 
again able to attend to her household duties. 

Treatment of Faulty Eating (Tachyphagia and Brady- 
phagia). — All persons who eat too fast should be warned 
by their physicians. They should be told to take more 
time for their meals and to chew their food thoroughly. 
If the time for eating is occasionally too short, as in 



AKT OF EATING. 7 

railroad journeys, etc., it is better to omit the meal or to 
take only something fluid (a glass of milk, a raw egg, or 
some beef -tea). 

To combat bradyphagia — observed in neurasthenics, 
and only rarely even in them — we must take active 
measures, as it is impossible to cure them as long as this 
condition exists, owing to the too small quantity of 
food ingested. They should be told to eat more, and 
more rapidly, and not to take too small bites or to chew 
too long. Fluids must be taken in larger quantities (not 
teaspoonfuls at a time). They should not take their 
meals apart from the rest of the family, but should eat 
at the common table and finish at the same time as the 
others. 

Frequently these instructions alone will be sufficient to 
correct this fault. If, however, this is not the case, then 
we must take refuge for a time in sedative drugs (bro- 
mides, valerian, etc.), in order to allay the psychic ex- 
citement during the time of eating. If the patient, with 
the aid of these drugs, has accustomed himself to take a 
few meals in a correct manner without suffering, he will 
then usually have enough confidence in himself with re- 
gard to his ability and will get along without medicines. 
The removal of bradyphagia will frequently smooth the 
path to convalescence and enable the patient to get en- 
tirely well. 



II. 

DIETETICS IN DISEASES OF THE STOMACH 
AND INTESTINES. 1 

Dietetics, or the doctrine of nourishment, has taken 
an important part in the treatment of the sick ever since 
the time of Hippocrates ; but, although the dietetics of 
the diseases accompanied by fever has not changed much 
in its chief points, new rules and principles regard- 
ing nutrition in chronic diseases have been introduced 
of late. This has reference especially to diseases of 
the stomach, that branch of internal medicine which 
in the last two decades has shown so much unlooked-for 
progress. As the therapeusis of diseases of the stomach 
has to deal with dietetics principally, I thought it would 
be of interest to discuss this subject before you. It will 
be expedient to divide the subject of diet in gastric af- 
fections into three parts : 

1. General rules of diet in diseases of the stomach. 

2. Dietetics in acute diseases of the stomach. 

3. Dietetics in chronic diseases of the stomach. 

1. General Rules of Diet in Diseases of the Stomach. 
— Within the past two years important facts have been 
discovered which are of the greatest value in the treat- 
ment of diseases of the stomach, and the influence of 
which can be perceived like a red thread through the 
whole chapter of dietetics. It has been shown by von 

1 Read before the Medical Society of the County of New York, 
May 22d, 1893. Medical Record, June 24th, 1893. 

8 



DIET EN" DIGESTIVE DISOEDEES. 9 

Noorden 1 and others that emaciation in chronic diseases 
of the stomach is caused in the largest majority of cases 
— if, perhaps, not in all — not by specific poisons circu- 
lating in the organism, but by a smaller amount of food 
being taken. On the other hand, one might expect, 
judging from the universal law existing in the plant and 
animal kingdom of vicariousness or replacement in case 
of inability of the work of one organ by another similar 
one, that, in grave disturbances of the digestive func- 
tions of the stomach, the intestines would do the work 
instead. This has been experimentally, as well as 
clinically, proven in the most positive way. Several 
authors (Leube, Ewald, von Noorden) have observed 
that in cases of atrophy of the mucous membrane of 
the stomach, in which, as you all know, the gastric se- 
cretion has entirely ceased, the patients can maintain 
their usual weight. From my paper on achylia gastrica 2 
it is clearly seen that patients can do very well with- 
out gastric secretion ; under a proper regimen they can 
even gain in weight and live long without any discom- 
fort whatever. This means that, even after the loss of 
the entire chemical action of the stomach, the gut is 
completely able to replace the function of the stomach. 

These two facts— (1) that the emaciation in chronic 
diseases of the stomach is caused by too small a quantity 
of food; (2) that even in grave lesions of the gastric 
functions the gut appears to perform vicariously the di- 
gestive work in a complete way — are of vital importance 
for the doctrine of dietetics. For it is seen at a glance 
that the main object of nutrition of the sick consists in 
giving them sufficient quantities of food. 

Before proceeding it is necessary to review briefly the 

1 Von Noorden: Berliner Klinik, Heft 55. 

2 Max Einhorn : Medical Record, 1892. 



10 DIET AND NUTBITION. 

normal physiological nutrition of man. We perceive at 
once that there is a great variety in the diet of healthy per- 
sons with regard to the quantity as well as the differ- 
ent food substances. Nevertheless, they all contain the 
three groups of food-stuffs — albumins, carbohydrates, 
and fats. Thus, for instance, vegetarians live and thiive 
principally on vegetables ; the Esquimaux, on the other 
hand, almost exclusively on animal diet. The golden 
path, however, lies in the middle, and all authors (Voit, 
Pettenkofer, Hoffmann, Forster, and Gruber) recom- 
mend a combination of animal and vegetable food, E. 
Yirchow, likewise, is of the same opinion, and exjuesses 
himself regarding this question as follows: " Although 
the Kirghez and the Esquimaux show us that health and 
life can exist through many generations on an exclus- 
ively nitrogenous diet — other tribes (Hindoos) live prin- 
cipally on non-nitrogenous food — still history shows us 
that the highest attainments of the human race haye 
emanated from nations who have lived and live on 
mixed diet." 

A mixed diet, taken partly from the vegetable and 
partly from the animal kingdom, is the most suitable 
form of nourishment. We obtain the greatest amount 
of carbohydrates from the vegetable kingdom, while 
a great deal of the albumin is derived from animal food. 
The relation between animal and plant albumin, ac- 
cording to Munk and Ufflemann, 1 should not be less 
than three to seven. As regards the quantity of food, 
according to the same authors, an adult doing a medium 
amount of work requires daily 118 gm. albumin, 56 gm. 
fat, and 500 gm. carbohydrates. 

Food only to a small extent serves the purpose of re- 

1 Munk and Ufflemann : " Die Ernahrung des gesunden und 
kranken Menschen," Wien, 1887. 



DIET m DIGESTIVE DISORDEKS. 11 

constructing tissue waste ; in its largest part, however, it 
is utilized for generating the heat requisite for the main- 
tenance of life. For that reason it is customary to speak 
of the necessary amount of heat-units during twenty-four 
hours instead of the quantity of food. By "heat-unit " 
is meant, as is well known, that quantity of heat which 
is required to raise the temperature of 1 gm. of water 
one degree Celsius. "Great heat-unit " means the 
amount of heat required for warming 1,000 gm. of water 
one degree Celsius. Each kind of food is ultimately oxi- 
dized in the body into its end-products, and is in greatest 
part exhaled in the form of carbonic acid; the more 
carbon atoms a food-stuff contains the more heat-units it 
will generate. In speaking of the heat value of food, 
the great heat-units are used, the term "great," however, 
being omitted. Thus 1 gm. of albumin generates 4.1, 1 
gm. of fat 9.3, and 1 gm. of carbohydrate 4.1 heat-units. 
If we know " the quantity of nourishment taken, the 
amount of the introduced heat-units is easily determined 
by multiplying the different food-stuffs by the above 
given figures. The daily amount of heat generated by 
the body, or necessary for the maintenance of the same, 
has been approximately estimated at 2,500 heat-units. 1 
The heat value of the food taken by an average working 
person amounts, according to von Noorden, 2 to about 
forty heat-units when working, and when resting to 
about thirty-four heat-units per kilo a day. According 
to K. Yierordt, 3 an adult takes in form of food a daily 
average of 120 gm. albumin, 90 gm. fat, 330 gm. carbo- 

1 Koenig: "Die mensckliclien Nahrungs- und Genussmittel," Ber- 
lin, 1883, p. 53. 

2 Von Noorden : Berliner Klinik, Heft 55. 

3 K. Vierordt: "Grundriss der Physiologie des Menschen," 1887, 
3. Aufiage, pp. 288, 289. 



12 DIET AND NUTEITIOX. 

hydrate (the relation of the nitrogenous food-stuffs to the 
non- nitrogenous being 1 to 4), and 2,818 gm. of water. 
The above-mentioned figures differ from those given by 
F. Hirschfeld. 1 This author demands 80 gm. of albumin 
as the lowest amount contained in a sufficient diet. Vic- 
tuals are composed mostly of all the three food groups 
(albumin, carbohydrate, fat) and water, and contain in 
minute amounts the inorganic salts found in the body. 

I give here a small table (see page 13), showing the 
percentage of the three food groups ordinarily contained 
in most everj^-day victuals. 

In order to have a correct idea of my own about the 
quantity of nourishment consumed daily, I have weighed 
and recorded for two successive days all the victuals and 
drinks taken by my wife and myself. The record showed 
that I had taken during the first test-day 63.8 of albu- 
min, 47.3 of fat, and 168.8 of carbohydrate; the total 
number of heat-units was 1,402.3. During the second 
test-day the corresponding figures were somewhat higher ; 
the quantity of albumin was 79.30, fat, 54.3, carbohy- 
drate, 263.9 ; the total of heat-units equalled 1,912.5. 

The average figure of heat -units per day was 
U02 +1912.5 __ 1657 4 As my weight is 52 kilogj tbe 

amount of heat introduced into the system per kilo and 
perdaywas^=32.3. 

My wife partook during the first test-day 103.19 of al- 
bumin, 44.99 of fat, and 204.64 of carbohydrate. The 
total of heat-units was 1,660.5. On the succeeding day 
the figures were as follows: 64.03 of albumin, 31.14 of 
fat, 174.92 of carbohydrate. The total of heat-units was 
1,269.29. The average figure of heat-units per day was 

1 660.50 + 1,269.29 _ -. , ~ . go 



F. Hirschfeld: Berliner klin. Wochenschr., 1893, No. 14. 



DIET IN DIGESTIVE DISOEDEES. 



13 



Composition of the Most Common Food Substances. 1 





Albumin. 


Fat. 


Carbohydrate. 




Per cent. 
4.0 to 4.3 

Yb 

5.0 

0.5 

3.0 

3.35 

25.0 
33.0 
18.0 
15.5 
22.0 
22.0 
23.0 

0.4 
6.0 to 7.0 

0.5 

r 9.0 to li.o 

J albumin 
1 +1.79 to 6.5 
I pepton 

4.95 

12^ 

0.5 
8.0 to 10.0 

1.5 

8.8 

10.0 
6.0 
V/% 
6.82 
9.5 
2.0 to 5.0 
2.0 
W% 
19^ 
19^ 

m 

12.5 

8.31 

64.5 

i8y 2 

193^ 
28.4 

3.49 

3.12 
12.38 

1.2 

0.4 

0.5 

0.7 


Per cent. 

3.0 to 3.8 

90.0 

3.25 

0.3 

1.3 

2.07 -j 

30.0 
9.0 
2.0 
1.0 
0.4 
1.0 
1.0 
0.6 
0.5 
0.5 

0.37 
12.0 
traces 

1.0 
3.5 
VA 

2.0 

M 

1.0 

0.77 

1.0 

0.4 

0.3 

2.0 

2.0 

5.26 

0.81 
5.24 

y 2 

17.0 
16.26 

0.58 

5.18 

0.09 

0.6 

5.25 

6.0 


Per cent. 
3.7 


Butter 


Y2 

15.0 
36 


Milk-soup with wheat flour 


Buttermilk 


3.0 


Kumyss (of cow's milk) 


0.7 lactic acid 




0.8 carbonic acid 
30 


Cheese 

Beef (lean) 


5.0 

1 


Veal 




Sweetbread 




Poultry 












Meat-juice (pressed) 

Beef- tea 




Leube's solution 

Oysters 




Egg... , 


86 5 


Sago 


Malt extract •. 


55 


Barley-soup 


110 


Rice pap with milk 


28 6 


Wheat flour 


73 


Rye flour 


69 


Wheaten bread 


52 


Rye bread 


46 


Roll 


43 72 


Zwieback 


75 


Cauliflower 


40 


Asparagus 


25 


Rice 


76 


Beans 


52 


Peas 


54 


Potatoes 


20 


Oatmeal 


66 77 


Barley -meal 


75 19 


Pulverized meat 


2.28 




Yb 

7.82 


Salt herring 


Caviare 


Spinach 


4.44 


Coffee 




Tea 




Pickles 


0.95 


Meat-broth 




Beer 


0.3 


Porter 


03 







1 Taken from Koenig, loc. cit., and principally from Munk and 
Ufflemann, loc. cit. 



U DIET A2s T D XUTBITIOK 

As iny wife weighs 55 kilos, the amount of heat-units 
per kilo and per day was therefore ^|- 89 = 26. 63. 

My wife, as well as myself, hold our weight, live reg- 
ularly, and the food taken is not subject to very great 
differences; therefore, the figures mentioned may be 
considered as our average ones. These figures, how- 
ever, are far smaller than the average given by all 
authors. This shows what great differences there are in 
the quantity of food taken by people in their normal con- 
dition in order to make up the daily loss. The one 
maintains his balance at a rate of 26 heat-units per kilo 
a day ; the other may lose in weight at 30 heat-units per 
kilo a day. The scale is the best guide as to whether a 
certain amount of food is sufficient or not. It shows 
quickly and with certainty whether the organism main- 
tains its balance or not. 

After this lengthy dissertation on the diet in health, 
let us return to the sick. 

As people with disturbances of the stomach have to 
replace for their existence no smaller losses than under 
physiological conditions, they will therefore need: 1. 
Just as large amounts. 2. The same kinds of food- 
stuffs as described for the normal state. The only differ- 
ence possible will have reference to the selection of the 
various articles of diet and to their form and special 
preparation. 

Thus the question arises, What qualities should the 
food of stomach patients possess ? 

In the treatment of a diseased organ one can often 
make use of two methods. One consists in sparing the 
diseased organ and giving it perfect rest; the other con- 
sists in strengthening the same by methodical adaptation 
for more work and practice. Both principles are, in 
fact, realized in the treatment of diseases of the stomach. 



DIET IX DIGESTIVE DISOBDEBS. 13 

The first method is ordinarily applied in acute diseases, 
and only very seldom (and then only for a short time) 
in chronic affections of Sue stomach. In the latter the 
second principle, as a rule, is used. The stomach can 
be spared, firstly, by not introducing into it any food 
whatever (greatest degree of saving or rest). Secondly, 
by administering food substances which, during their 
stay in the stomach, do not impose much work upon this 
organ, and do not greatly irritate it. Here the main ob- 
ject will be to give the patient easily digestible food. 
In turning from the saving principle to that of strength- 
ening the organ by methodical adaptation for work, it 
will be quite natural to change the diet, not suddenly, 
but gradually, into such as requires more work on the 
part of the stomach for the digestion. It is therefore ab- 
solutely necessary to have an exact table of the digesti- 
bility of different foods. In prescribing or changing a 
diet we shall have to act according to it. Such a scale 
has been arranged by different authors. The main sign 
of digestibility was gauged by the rapidity with which 
the various food-stuffs passed out of the stomach into 
the intestines. Beaumont, in many trials on his patient 
with the gastric fistula, determined the length of time 
the different victuals remained in the stomach, and con- 
structed a scale according to the figures obtained. ' On 
the same principle, but more reliable and of greater 
value, is the scale constructed by Leube, according to the 
results obtained by emptying the stomach by means of the 
tube, after different kinds of food had been taken. We 
think it advisable and useful here to give Leube 's 
scale : 

1. Diet — Bouillon, Leube -Bosenthal's meat solution, 
milk, soft-boiled eggs, zwieback, English cakes (biscuits 



16 DIET AND NUTEITIOK 

containing no sugar), water, natural acidulous waters 
(Apollinaris, Kronthaler, Seltzer, etc.). 

2. Diet.— Boiled calf's brain, boiled calf's sweetbread, 
boiled chicken (young without the skin), boiled pigeon, 
boiled calves' feet, tapioca pap boiled in milk, beaten 
white of egg. 

3. Diet. — Eaw beef (chopped very fine), raw ham 
(chopped very fine), beefsteak (superficially fried in 
freshest butter), finely scraped tenderloin of beef, 
mashed potatoes, white bread (stale), coffee with milk, 
tea with milk. 

4. Diet. — Fried chicken, fried squab, roast venison, 
guinea hen, roast beef (cold), roast veal (leg, saddle), 
boiled pike, macaroni, rice pap, finely chopped spinach, 
asparagus, stewed apples. 

These tables, however, have not as yet, on the one 
hand, been fully verified on healthy individuals or found 
always alike (giving the same results) ; on the other 
hand, such experiments only show what food remains in 
the stomach the shortest time. This would perhaps give 
reason for assuming what food may be easily digested as 
far as the stomach is concerned, but not what is most easi- 
ly digested as a whole, i.e., utilized for the economy with 
the smallest amount of work. The digestibility of food 
substances depends, first, upon their shape and qual- 
ity ; secondly, upon their percentage of convertible ma- 
terial. 

" Corpora non agunt nisi fluida," is an old, well- 
known axiom. Following this law one could arrange the 
following scale of digestibility, which is constructed ac- 
cording to the different physical conditions of the food : 

1. In the first place, food in liquid form : (a) Liquid 
at ordinary temperature — milk, meat-juice, beef -tea, 



DIET IN DIGESTIVE DISOEDEES. 17 

bouillon, peptone or sarcopeptone dissolved in water, 
bread- water, 1 strained barley, oatmeal, rice-water, 
strained oyster-soup, egg albumin- water ; (&) liquid at 
the body temperature — jellies, fruit-jelly, calf s-foot 
jelly, ice-cream, water-ice. 

2. Pulpy form: The food is mechanically converted 
into very minute particles and well mixed in liquid — pap 
soups (barley, oatmeal, farina, rice, sago) ; egg in bouil- 
lon; Leube's meat solution, pulverized meat, pulverized 
crackers in milk, water, or bouillon; buttermilk; ku- 
myss; cream; butter. 

3. Food which by slight trituration in fluids separates 
into minute particles : White bread in milk or water ; the 
tips of well- boiled asparagus ; carrots ; mashed potatoes, 
baked potatoes; the yolk of hard-boiled eggs; oysters 
(raw). 

4. Solid food: White bread, rye bread; meat, hard- 
boiled eggs, fish, cheese. 

5. Substances not easily digested: Meat with tough 
fibre ; lobster ; sausages and Swiss cheese on account of 
their solidity ; all substances containing much cellulose, 
particularly when eaten raw ; cole-slaw ; all salads, cu- 
cumbers, pickles, raw fruit, apples, pears, pineapple; 
fruit which contains much acid, therefore all unripe 
fruit, strawberries ; substances containing much sulphur 
and forming gases in the intestines ; all kinds of cabbage, 
principally white cabbage ; beans. 

This theoretically constructed scale of the digestibility 
of food is, at the same time, in the main points, similar 
to the one which has long stood the test of empiricism 
and which I ordinarily apply in my practice. 

1 Bread-water. Stale bread is cut into slices and put in water at 
temperature of room for from two to three hours, then the water is 
strained. 



18 DIET AND NUTRITION. 

After these general explanations we return to our spe- 
cial subject. 

Dietetics in Acute Diseases of the Stomach. — The princi- 
ple of rest here occupies the first place. In acute gastric 
catarrh one gives, during the first two or three days, in 
which, usually, there is a total loss of appetite, only 
very little nourishment in liquid form, containing prin- 
cipally amylacea, barley or oatmeal soup, bouillon, weak 
tea, water. As a rule, one must not force a patient to 
take food during the first or even during the second day 
of sickness. The anorexia in these conditions is a wise 
arrangement made by nature in order to give the stom- 
ach rest. If there is thirst, beverages may be taken in 
small quantities, and must be neither very cold nor very 
warm. As soon as the appetite reappears one iuslj give 
some toasted bread or zwieback, milk, soft-boiled eggs, 
or oysters, permitting, after a while, small quantities of 
bread and meat, and then passing slowly to the ordinary 
diet. 

Ulcer of the Stomach. — During the rest cure of von 
Ziemssen-Leube give liquid diet, consisting principally of 
milk, for two or three weeks. As is well known, Cru- 
veilhier 1 first recommended milk for this purpose, and 
even now there are some physicians who limit themselves 
to milk alone. As a rule, however, it is appropriate to 
allow, besides milk, milk in combination with barley, 
oatmeal, or rice-water. In addition to this, the different 
peptone preparations are here in place. I administer 
Rudisch's sarcopeptone, manufactured in this country, 
on account of its being palatable and highly nourishing. 
(The Rudisch's sarcopeptone contains forty per cent of 
nitrogenous substances, including twenty per cent of 
peptones. ) 

1 "x\natomie Pathol.," 1829-P,.""). 



DIET IN DIGESTIVE DISOEDEBS. 19 

One may give most appropriately every three hours 
one to two cupfuls of milk with or without the addition 
of the above-named decoctions (four times daily) and 
sarcopeptone (twice daily). The patient must not drink 
these fluids, but eat them with a spoon. In case of hem- 
orrhage from the stomach, during the first three or four 
days it is not permitted to give any food whatever by 
the mouth ; instead, the patient must be fed by the rec- 
tum. Ewald has proven that the large intestine has the 
ability of digestiug and absorbing albuminates even with 
out special previous preparation ; therefore the follow- 
ing may be given as a nutritive enema : 

1. Three to five eggs are mixed with 150 c.c. of sugar- 
water (30 gm. of grape-sugar dissolved in 150 c.c. of 
water), a small quantity of common table-salt is added, 
and the whole mixture well beaten ; one may add also a 
small quantity of starch solution or mucilage. 

2. One-half pint of milk -f 2 eggs + 50 gm. of grape- 
sugar. 

3. One-half tablespoonful of Eudisch's sarcopeptone 
or plasmon dissolved in a cupful of water. 

The food enemata have to be given three or four times 
daily. It is necessary that the fluid should be at the 
temperature of the blood, and that it should be injected 
by means of a fountain syringe and a soft -rubber rectal 
tube. Every morning a cleansing enema of one quart of 
saline should be given, in order thoroughly to cleanse the 
large intestine and make it more fit for absorption. In 
case of thirst the patient is allowed to take small pieces 
of ice into the mouth from time to time. Three days 
after the disappearance of blood one slowly and cau- 
tiously begins the liquid diet. 

Dietetics in Chronic Affections of the Stomach. — While 
in acute diseases of the stomach we paid most attention 



20 DIET AND NUTEITION. 

to giving rest to the organ — for here even an insufficient 
nutrition and the loss of several pounds of bodily weight 
is not of much importance, as the quickly recuperating 
organism replaces the losses caused during the sickness 
by taking increased quantities of food — in the chronic 
affections it is of utmost and vital importance to see 
that sufficient quantities of food are taken. 

The greatest number of stomach patients consulting 
the physician, after the disease has been progressing 
quite a while, have lost more or less weight. The prin- 
cipal reason for this lies in the fact that the body has 
received too small a quantity of nourishment in order to 
replace the waste. 

The ordinarily insufficient appetite, the early appear- 
ance of a feeling of satiation, the pain often appearing 
after meals, and less frequently vomiting, are the prin- 
cipal factors of subnutrition. 

At this point it becomes necessary to divide patients 
with stomach troubles into two large classes : 

1. Those with organic lesions of the stomach. 2. 
Those with functional disturbances. 

The first class comprises (a) the malignant diseases of 
the stomach itself or its orifices (carcinoma ventriculi, 
cardise, pylori) ; (b) cicatricial strictures of the cardia or 
pylorus ; (c) absence of secretory work of the stomach : 
achylia gastrica. 

In this whole first class, with the only exception of 
group c, which lies, so to speak, between the first and the 
second class, we are unable to accomplish much either by 
treatment or dietetics. In existing strictures of the car- 
dia or pylorus one will be obliged to seek surgical aid. 
Even in cancer of the stomach -wall the resection of the 
affected part is advisable whenever the operation is pos- 
sible. I cannot abstain from calling attention at this 



DIET IN DIGESTIVE DISORDEES. 21 

place to the splendid results of the recent stomach sur- 
gery, which of late has been frequently practised in our 
own country (F. Lauge, N. Senu, E. Abbe, Willy Meyer, 
McBurney, Weir, Murphy, McGraw, Mayo, Bull, Mar- 
koe, Syms, and others). In carcinomatous strictures a 
new passage can be established, either for bringing food 
into the stomach by a gastric fistula, or for allowing it 
to pass iuto the intestines by gastro-enterostomy. In 
this way one succeeds at least in temporarily giving these 
unfortunate ones relief and in ameliorating their nutritive 
condition. In the cicatricial strictures one is warranted 
in promising to the patients, nowadays, perfect recovery 
if they will submit to operative treatment. (In strict- 
ure of the cardia a methodical dilatation of same with 
bougies may sometimes also suffice. ) The pyloro -plastic 
operation (of Heincke-Mikulicz) and the cardiotomy or 
cardio-fissure (Abbe) belong to the most beautiful and 
beneficent operations which have ever been practised. 
After the operation the patients are enabled to eat every- 
thing and to live without any trouble whatever, i.e., 
they are perfectly cured. 

Before the oxDeration, or if such is not feasible, one 
will administer light, very slightly irritating nourish- 
ment, and always endeavor to make the patient partake 
of a larger quantity of food. If there is obstinate and 
constant vomiting, it is necessary to employ nutritive 
enemata. 

Group c, achylia gastrica, will be advantageously dis- 
cussed in regard to diet under Class 2. 

The second class of functional disturbances includes 
the largest number of all dyspeptics. Here stand up- 
permost chronic gastric catarrh, atony of the stomach, 
dilatation of the stomach, gastroptosis, superacidity, 
with or without hypersecretion, nervous gastralgia, ner- 



22 DIET AND NUTRITION. 

vous dyspepsia, and, as an intermediary between the first 
and the second class, achylia gastrica. 

It appears advisable to discuss first the whole class, 
and thereafter to give special rules for the different 
groups. Liquid food or partly predigested substances 
(as all peptone preparations) are not in place here. By 
making the stomach work too little, the weakened condi- 
tion of this organ is retained and aggravated in time. 
We must always bear in mind the principle of strength- 
ening the organ by means of appropriate work. 

Delafield ' is said to express himself in his lectures in 
the following way regarding the dietetics of the dys- 
peptic : 

When a dyspeptic patient asks you the question, 
" What shall I eat? " reply, "Eat what you like." If he 
asks, "How much shall I eat?" say to him, "Eat as 
much as your appetite demands." If he still asks, 
"When shall I eat?" answer, "Eat when you are hun- 
gry." 

Although I do not favor strict and severe dietetic 
rules, nevertheless I deem the above-mentioned remarks 
as going too far. Unlike the normal healthy condition, 
in which instinct shows us the right measure to eat, 
neither too little nor too much, stomach patients very 
often have lost the feeling of self- regulation, and as a 
rule partake of too small quantities of food. (Only in a 
few cases of boulimia there may be an increased desire 
for food, and in connection with it the quantity of nour- 
ishment taken may sometimes be too large. ) It is there- 
fore necessary to instruct the patients to eat more, or to 
give them exact figures of the quantity of food required. 
As this varies with every individual, it is most practicable 

1 Cited from Kellogg: "Methods of Precision in Disorders of Di- 
gestion," 1893, p. 4. 



DIET IN DIGESTIVE DISOEDEES. 23 

to let the patient weigh himself once a week and to see 
whether he keeps his weight. If the patient does not 
lose any it is the best sign that he takes sufficient nour- 
ishment. Besides, we must remind patients to lead a 
regular life, to eat slowly (how many, especially in our 
country, sin against this natural law), and to chew well 
and triturate the food. One must avoid either extremely 
cold or extremely warm food. Too copious and too com- 
plicated meals must be strongly forbidden. 

I have made it a rule not to forbid anything, except 
what is, according to my conviction, obnoxious in the 
given case. In this way the patients have a great vari- 
ety in their food and run less risk of subnutrition. Like- 
wise we need not change the number of meals nor the 
hours appointed unless there should be special indications 
for such a proceeding. 

Among the laity, as well as often among medical men, 
there are prejudices against certain forms of food. Thus, 
for instance, until recently one forbade all kinds of fat, 
even butter, in all dyspeptic conditions. Fat, however, 
belongs to the group of food-stuffs which has the largest 
number of heat-units, and, besides, is not bulky as a 
nourishment (butter). Undecomposed fat passes the 
stomach without molesting the same, and is digested in 
the small intestine. There is, therefore, no reason for 
forbidding butter, which should, on the contrary, be 
highly recommended. Fearing fermentative processes 
the partaking of bread and other food rich in carbohy- 
drates is very often greatly limited or even totally for- 
bidden. Although it is true that the carbohydrates 
easily undergo fermentative processes, yet those cases 
in which considerable fermentation exists in the stomach 
are quite rare, and as a rule are found only where there 
is considerable stagnation of food in the stomach. In 



24 DIET AKD KUTKITION. 

these cases, to be certain, a diet consisting principally of 
animal albumin (meat) for a short period is very useful. 
By means of lavage of the stomach and other appropriate 
treatment one soon succeeds in checking the fermenta- 
tive processes, and one can then administer carbohy- 
drates. 

An adult, according to Koenig, x daily consumes one- 
third to three -fourths kilo of bread ; fifty to sixty per 
cent of the total food substances, and fifty to seventy - 
five percent of the carbohydrates are taken in the form 
of bread. This clearly shows the important part bread 
plays in diet. Its use is, therefore, as a rule advisable. 
It is ordinarily said that crust of bread, stale bread, and 
zwieback are easier to digest, on account of the starch 
contained in them being largely converted into dextrose. 
Although I am of the opinion that too fresh bread must 
be avoided, I nevertheless rarely find much difference in 
the digestibility of the crust or other parts of well -baked 
fine white bread, judging from experience gained from 
my own patients. 

Articles of luxury (wine, beer, coffee, tea) are, as a 
rule, permissible. It is, however, necessary to give them 
in small amounts and in appropriate form. Strong liq- 
uors must be avoided, likewise all strong spices. 

Appetizers, as a small amount of caviare, sardellen, 
or anchovies, on a small slice of bread or cracker, taken 
one-quarter of an hour before the meal, are not only al- 
lowed but frequently directly commendable. 

In reference to the special rules for the different dis- 
eases of the second class, we shall have at times to reduce 
the quantity of meat taken in all conditions accompanied 
by a diminished secretion of HC1 (gastritis chronica 

1 Koenig: "Die menschlichen Nahrungs- und Genussmittel," Ber- 
lin, 1883, p. 430. 



DIET IK DIGESTIVE DISOEDEES. 25 

glandularis, atony -f- subacidity) ; on the other hand, the 
quantity of richly carbohydrate vegetable food will be 
increased. Kumyss, niatzoon, milk with cognac (7 to 10 
c.c. of cognac to 200 or 250 c.c. of milk) may be taken 
with crackers either during or between meals. 

In all the conditions with superacidity the quantity of 
albuminous food should be increased ; here one may give 
a great deal of meat (venison included). In superacidity 
with hypersecretion frequent and small meals containing 
consistent food are most appropriate. If there is a feel- 
ing of hunger between meals, the white part of hard- 
boiled eggs may be taken (as is well known, albumin 
combines with acid and makes it, so to say, inert). The 
quantity of beverages must be greatly limited ; most suit- 
able in this instance are small quantities of vichy water. 
In dilatation of the stomach and in gastroptosis it is also 
advisable to give small and frequent meals and to restrict 
the quantity of liquids taken. As a rule, milk and beer 
do not agree well in these cases. Small quantities of 
wine or imported dark beer or porter may be allowed. 

In nervous dyspepsia and gastralgia our main object 
will be systematically to increase the quantity of food — 
here milk and its derivatives (kumyss, matzoon, bonny 
clabber, buttermilk, cream), taken between meals, play a 
prominent part (Weir-Mitchell treatment). 

In achylia gastrica it is of utmost importance to give 
at first liquid or very well -triturated (pulverized) food. 
For here the chemical action of the stomach has entirely 
ceased, and vegetable (on account of the albuminous 
membrane enclosing the starch granules) as well as ani- 
mal foods pass from the stomach unchanged, and not con- 
verted into small particles, into the intestines and irritate 
them, unless there has long been formed a sufficient 
adaptation for these conditions. Vegetable food, on ac- 



26 DIET AND NUTBITION. 

count of its containing chiefly carbohydrates, should 
predominate in the diet of this affection. Thus achylia 
gastrica, in reference to diet, stands midway between 
the first and second classes. It approximates to the first 
class in so far that it necessitates liquid or a mechani- 
cally minutely triturated or pulverized food, the second 
class in allowing a richly carbohydrate diet. After a 
short period of this diet, bread, gruels, soft-boiled eggs, 
cottage cheese may be added. Later on I usually allow 
also tender meats once daily. 

Some readers may miss in my paper exact bills of fare 
for chronic affections of the stomach. They have been 
omitted, as it is always necessary to individualize, espe- 
cially in diet. We must guide ourselves more by the pa- 
tients than by theoretical conclusions. Our main object 
must be to care for a sufficient nutrition. Only the 
above-given principal rules on diet must be observed, 
although at times even they have to be modified. In 
reference to this point Hippocrates ' said: u Dandum ali- 
quid tempori, regioni, cetati et consuetudini." 

At present, with our more exact knowledge, we have 
come to appreciate this conclusion to a still greater de- 
gree. 

The Diet in Diseases of the Intestines. — The general 
rules are the same as for the diseases of the stomach. 
Acute disturbances must be treated on the principle of 
rest, permitting only liquid and semi-liquid foods in 
small or moderate quantities. As a rule, everything 
should be served warm. In acute enteritis coffee, cold 
drinks, acid lemonades, and all fruit juices should be 
strictly forbidden. In acute appendicitis, intestinal ob- 
struction, etc., either no food at all or very small quanti- 
ties of liquid food (white-of -egg water, milk mixed with 
1 Cited from Munk and Ufflemann, I. c, p. 430. 



DIET IX DIGESTIVE DISORDERS. 27 

strained gruels, bouillon, weak tea) should be adminis- 
tered. 

In chronic affections of the intestines it will be neces- 
sary to provide for a sufficient nutrition. In organic 
affections (stricture, cancer of the intestines) an entero- 
enterostomy should be performed, in order to allow ade- 
quate nutrition. But before this operation is undertaken, 
or if the latter be not feasible, liquid nourishment and 
small amounts of tender meat, also raw or very soft- 
boiled eggs with butter, will be permissible. Foods hav- 
ing considerable residues of undigested material must be 
forbidden. 

In chronic enteritis and all functional disorders of the 
bowel, ample nutrition and training this organ to do its 
proper work should be the aim of treatment. In con- 
ditions accompanied by diarrhoea, fruits, salads, cold 
drinks, and highly spiced foods should be interdicted. 
Otherwise there should be no restrictions in the diet. 

In affections of the bowel with constipation, the so- 
called "laxative " foods (fruits, salads, green vegetables, 
brown bread, whole-wheat bread, Boston brown bread, 
etc. ) play an important part in the diet. The patient 
must be encouraged to eat ordinary foods and to partake 
liberally of the articles just mentioned. 



III. 

THE DIET OF DYSPEPTICS. 1 

A few years ago I had the honor of reading a paper 
before this society, on " Dietetics in Diseases of the 
Stomach. " 2 To-night I wish to discuss more fully a few 
points which are of eminently practical importance, and 
which I had at that time broached only superficially. 
The majority of dyspeptics, or of patients suffering from 
chronic digestive disorders, are affected with functional 
or nervous derangements. Most of these patients suffer 
either from loss of appetite or from gastralgia, some- 
times from both, and hence take inappropriate and in- 
sufficient nourishment. Thus some live on small quanti- 
ties of peptonized milk ; others on artificial meat extracts 
(beef -juice, liquid peptonoids, etc. ). If these dyspeptics 
adhere strictly to this rigorous diet, they almost always 
depreciate more and more in health. 

A marked fear of food is distinctly observed in all 
these cases. This symptom I would like to designate as 
"sitophobia" (fear of food). If the patients give in to 
this sitophobia — which frequently occurs — the dyspeptic 
symptoms increase more and more, even after the inges- 
tion of small quantities of liquid and predigested foods. 
Soon varied symptoms of inanition manifest themselves, 

1 Read December 21st, 1897, before the Section on General Medi- 
cine of the New York Academy of Medicine. Medical Record, Jan- 
uary 1st, 1898. 

2 Einhorn, M. : New York Medical Record, June 24th, 1893. 

28 



DIET OF DYSPEPTICS. 29 

such as dryness in the throat, headache and dizziness, a 
feeling of decided weakness, intense ansemia, sometimes 
even pernicious anaemia. 

Should we therefore be astonished if such patients, ad- 
dicted to this wrong course of living, gradually waste 
away and finally succumb ? 

Either inanition itself, or complications arising in con- 
sequence of malnutrition, may easily bring on a fatal is- 
sue. As a whole, it is rather surprising how long these 
patients can live in spite of insufficient nutrition. This 
goes to show how tenaciously the organism clings to life ; 
it learns to economize its expenditures and to subsist on 
scanty means. This is the only explanation why these 
invalids, who, after at first losing considerably in flesh, 
subsequently maintain their slight bodily weight aud are 
able to lead a meagre existence. 

Gentlemen, the number of such emaciated dyspetics is 
not small, and every practitioner meets with a few of 
them every year. 

I will now present a few points by means of which 
these cases may be recognized. 

Generally speaking, the term dyspeptic signifies one 
who suffers from a chronic disorder of his digestive or- 
gans, without having, however, any organic affection. 

We will have to determine, first, the presence of some 
protracted ailment (for one or several years); second, 
the absence of any organic disease (ulcer, stenosis) of the 
stomach or intestines. An examination of the gastric 
contents may be omitted in these cases, although the 
knowledge of the chemical conditions of the gastric juice 
may sometimes be useful with regard to the treatment. 

How shall we treat such dyspeptics ? Medicaments are 
not of much value or play only a subordinate part. The 
main factor lies in proper nourishment. These patients, 



30 DIET AM) NUTRITION. 

who have abstained from most kinds of food for years, 
must now learn anew to eat. Their stomach and intes- 
tines very quickly adapt themselves to this new condi- 
tion. First and above all, it is of importance to increase 
the quantity of nourishment ; second, to provide a suffi- 
cient variety of foods. An ample but too one-sided diet 
(as a purely milk diet, or hot water and beef) is not suit- 
able for a long period of time, for under this regimen 
there may be a partial lack of certain substances neces- 
sary for the welfare of the organism, and thus there may 
be exerted a deleterious action upon the economy. 

In order to improve nutrition, two articles of food, 
which hitherto have been often avoided by laymen as 
well as physicians, play an important part. I mean bread 
and butter. In my previous paper I have already hinted 
at this topic ; I now take the liberty of again discussing it. 

Bread forms one-third of the total amount of ingested 
food in health, and, besides having nutritive value, serves 
the purpose of increasing the flow of saliva during its 
mastication. It also creates an appetite for other food. 

Butter not only improves the taste of various kinds of 
food, but is also in itself a nutriment of the greatest im- 
portance. The great number of calories which butter 
contains (100 gm. give 837 heat units, while the same 
amount of bread develops about 217) shows this in the 
clearest manner. Another advantage which butter pre- 
sents is that its volume is only about one-third that of 
bread. A patient taking about one-quarter of a pound 
of butter a day receives therewith more than one-half of 
the heat units required. This quantity of butter is, ac- 
cording to my experience, well borne by most of the pa- 
tients. 

I now take pleasure in presenting to you two cases, in 
which the main symptoms consisted principally of a de- 



DIET OF DYSPEPTICS. 31 

ficient nutrition. By improving the latter the patients 
got well. These two cases I take at random from a large 
number of a similar character. 

Case I. —Miss G. M , about 26 years old, suffered 

for the last five years continuously from marked dyspep- 
tic symptoms. Severe gastralgia often appeared, which 
was frequently accompanied by vomiting. The appetite 
was not greatly decreased, but, fearing the pains, the 
patient abstained from most articles of food. Obstinate 
constipation was another of the troublesome symptoms 
present. The patient ran down very fast. She was 
treated by several eminent physicians, and as a last resort 
the ovaries were removed. Her ailments, however, per- 
sisted, and she steadily grew worse. When she first con- 
sulted me she reported that she had lost sixty pounds in 
weight. The patient was abed the greater part of the 
time, and lived exclusively on small amounts of pepton- 
ized milk and Wyeth's beef T juice. 

A thorough examination of the patient did not re- 
veal any organic disease of the digestive apparatus. 
A condition of enteroptosis was found, but this was 
not considered important. The patient was ordered to 
take more nourishment. She was placed (during the 
first week) on a fluid and semifluid diet ; soon, however, 
the bill of fare was increased, and after about three or 
four weeks she partook of nearly all the plain and ordi- 
nary articles of food. During the first fortnight the pa- 
tient continued to complain of manifold severe symptoms 
after meals, but soon her complaints grew less frequent 
and after a while entirely ceased. The patient was 
plentifully nourished in a methodical way (among other 
directions she was told to take one- quarter of a pound 
of butter a day), and she gained fifty pounds in weight 
in a period of five months. After that time she could 



32 DIET AND NUTBITION. 

be regarded as restored to perfect health. She could 
take long walks without fatigue, she rode a wheel, aud 
atteuded to all her household duties. 

Case II. — Mrs. Caroliue A , 65 years old, had 

suffered for the last four years, off aud ou, from dyspep- 
tic symptoms. During the last five or six months her 
condition grew materially worse. The patient usually 
had severe pains after meals, and suffered from obstinate 
constipation, weakness, and insomnia. During this en- 
tire time she had been on a rigorous diet (beef -juice, 
etc.), and had been treated with various medicaments; 
but under this treatment she had lost thirty-five pounds 
in weight. The physician in charge and also her rela- 
tives were of the opinion that she had a cancer. A thor- 
ough examination revealed only a downward displace- 
ment of the liver and stomach. The liver at first 
simulated a tumor, but on further examination it could 
be easily seen that the latter was the prolapsed liver and 
not a neoplasm. 

The patient was told to partake of nourishment every 
three hours and was allowed certain articles of food 
which had been previously forbidden. At first zwie- 
back, crackers, and gruels were permitted, besides a 
small quantity of scraped beef. Soon, however, the 
ordinary white bread, butter, eggs, and similar sub- 
stances were added, and the patient began to gain in 
strength. (The wearing of an abdominal bandage was 
not advised, as the patient did not feel relieved when the 
lower part of her abdomen was supported with the hands 
when she was examined.) During a period of three 
weeks the patient gained eight pounds in weight, got rid 
of her dizzy spells, as well as her gastralgia, and could 
sleep much more comfortably. She is still under treat- 
ment, but her convalescence continues. 



DIET OF DYSPEPTICS. 33 

As nutrition plays the principal part in the treatment 
of these patients, it will not be amiss to give a few hints 
with regard to its management. To begin with, it does 
not appear advisable to permit patients who have ab- 
stained for a long while from the coarser varieties of 
food everything at once. This abrupt change may at 
times be the cause of various unpleasant symptoms; 
therefore it should be accomplished gradually. At first 
give, besides milk, gruels, and thickened soups, eggs 
beaten up in milk, etc. A few days later begin to add 
to this bill of fare zwieback or crackers with butter; 
then permit /meat, the white of chicken and well-scraped 
beef; next, mashed potatoes; still ]ater give wheaten 
bread, baked or boiled potatoes, soft-boiled or scrambled 
eggs, oysters ; at last allow vegetables and fruits. 

An essential point with regard to nutrition is punctu- 
ality in the taking of meals. In most of these cases, in 
which a gain in weight is of great importance, frequent 
meals (five or six daily) will be advisable. Although it 
does not appear advantageous to prescribe for the patient 
the quantities of the various foods in exact weight (grams 
or ounces) — as by so doing they are too easily reminded 
of their ability or inability to digest this or that quantity 
and not more — it is nevertheless of value to mention ap- 
proximate figures by which they may be guided or below 
which they shall not go. Thus, for example, they ma}- 
be told to eat as much as their neighbors at table, or 
that they shall take ten ounces of milk at this or that 
meal ; or, as I frequently advise, that they shall consume 
one-quarter of a pound of butter a day. Emphasize 
those points which appear to be the most important, and 
leave the patient great liberty in all other particulars. 
^Ye must strive to familiarize the patient with the idea 
that ample nourishment will strengthen his organs (in- 
3 



34 DIET AND NUTRITION. 

eluding the stomaeh and intestines), and we must always 
endeavor to dispel the fear of food with which he is har- 
assed. 

For patients who are greatly run down and are con- 
fined to bed a nurse is advisable, who shall see that the 
physician's orders (with regard to food) are promptly 
carried out. Massage may certainly be used on and off 
as an adjuvant. For patients who are up and about, a 
nurse is unnecessary. In the latter instance it is impor- 
tant to see that the patient's time is properly occupied ; 
by that I mean to say that the patients should lead a ra- 
tional mode of living, and should work neither too much 
nor too little. With some patients (wealthy people, hav- 
ing no vocation) we must try to give them something to 
do ; while in the case of merchants whose business strain 
is too great, lawyers, and physicians, we should advise 
that sufficient leisure be taken. The points just men- 
tioned serve in a high degree to render possible a healthy 
nutrition, for only a rational mode of living gives suffi- 
cient appetite for abundant food. 

In cases in which the condition of the gastric juice is 
known there are still other special rules with regard to 
diet; for, as is well known to you, we should give 
abundant quantities of meat in hyperchlorhydria, 
while in hypochlorhydria and achylia gastrica the 
starchy substances (and vegetable food) should pre- 
dominate. 

The above suggestions, however, play the principal 
part in the treatment, and good results may be ob- 
tained often enough without analyzing the gastric con- 
tents. 

Gentlemen, I have endeavored to give in this paper a 
few practical hints with regard to the nourishment of 
most patients afflicted with chronic stomach troubles. 



DIET OF DYSPEPTICS. 35 

If I have succeeded in convincing you that it is much 
more important to take care that such patients are sensi- 
bly nourished than to forbid them everything, I shall 
feel that my object has been accomplished. 



IV. 
SITOPHOBIA OF ENTERIC ORIGIX. 1 

Sitophobia, meaning fear of food, is a condition 
which may last a long period of time and, if not success- 
fully treated, may endanger life. It is therefore natural 
that this subject should command the full attention of 
the practitioner. 

When I first used the term sitophobia I was not aware 
that Guislain 2 had already employed the same word to 
designate the refusal of food which is so often encoun- 
tered in cases of melancholia and in the insane. For 
this condition, however, the word introduced by Sollier, 3 
namely, " sitieirgy , " meaning refusing food, seems to be 
more appropriate. For, in the insane, the patients do 
not want to eat, not because they are afraid of the food, 
but for different reasons ; either they are in a state of 
depression, unwilling to do anything, even eating, or 
they have suicidal ideas, or they have illusions that the 
food may be poisoned, etc. I may be, therefore, per- 
mitted to reserve the term sitophobia for those conditions 
only in which there is distinct fear of taking food on ac- 
count of resultant bad consequences. Sitophobia in this 

1 Read before the New York Academy of Medicine, May 16th, 
1901. Journal of the American Medical Association, June 15th, 
1901. 

2 Guislain: Eulenburg's "Realencyclopadie der Medicin," 1887, 
Bd. xii., p. 696. 

3 Sollier: Revue de Medecine, aout, 1891. 

36 



SITOPHOBIA OF ENTEEIC OEIGIIS T . 37 

sense has nothing to do with the insane and is fonnd in 
mentally perfectly sonnd people. 

In my paper, "The Diet of Dyspeptics," 1 I have 
already alluded to the importance of sitophobia and its 
management. 

While, however, in the above article sitophobia is 
spoken of as occurring in cases of disorders of the stom- 
ach, principally those accompanied by pains, of late I 
had the opportunity to observe the same condition in 
persons who had no gastric symptoms whatever and in 
whom "the feai of food " was due to some intestinal diffi- 
culty. I shall, therefore, in this paper speak of the lat- 
ter group of cases, or of "sitophobia of enteric origin." 

A good illustration of the importance of this condition 
will be found in the following case, which I beg to de- 
scribe : 

William H , 28 years old, bookkeeper, had always 

been well up to two and a quarter years ago. At that 
time he became constipated, which condition gradually 
grew worse, occasionally alternating with diarrhoea. 
Off and on, mucus was observed in the stool. His appe- 
tite was good, but he suffered at times from headaches 
and disturbed sleep. Patient consulted me for the first 
time in March, 1900, and was given magnesia usta in con-, 
junction with ferratin and olive-oil enemas, after which 
he improved for awhile. He went to the country, where 
his condition again became worse. On his return to the 
city, in August, patient was given podophyllin pills, 
which, however, did him no good. He then went to an- 
other physician, who ordered some medicine and injec- 
tions of water. 

These remedies not proving of benefit, patient again 
resorted to the podophyllin pills and injections every 
1 Max Einhorn: Medical Record, January 1st, 1898. 



38 DIET AND NUTRITIOK 

day, using both these means from September, 1900, to 
March, 1901. Often he would go without a movement 
of the bowels for seven to ten days. During all this time 
he ate much less than he was previously accustomed to, 
because he was afraid "that he would get entanglement 
of the bowel." His weight steadily grew less, and 
dropped from 138 to 101^ pounds. He became exceed- 
ingly nervous, irritable, and hypochondriacal. Of late 
he felt so weak that he had to abandon his vocation. At 
this time (March, 1901) he again consulted me, looking 
very badly, and being hardly able to walk. After un- 
dressing he looked almost like a skeleton, every bone be- 
ing visible, not unlike a Roentgen picture. 

On examination, besides this extreme condition of 
emaciation, pronounced ansemia was found. The thoracic 
organs did not present anything abnormal, while the ab- 
dominal cavity appeared somewhat caved in (almost 
trough-like) and showed an "apparent tumor," situated 
above the navel to the left of the spine. There were no 
areas painful to pressure. The urine contained neither 
sugar nor albumin. The knee reflex was present. 

The diagnosis of emaciation due to inanition without 
any organic trouble was made and the patient treated ac- 
cordingly. He was advised to eat six times a day ; a 
rectal injection of a half -pint of warm olive oil was or- 
dered every night, and he was given internally calcined 
magnesia and ferratin. He was told to eat plain, whole- 
some food, plenty of fruit, bread, and at least a quarter 
of a pound of butter daily. He immediately improved ; 
his bowels became regular, and hardly a month later he 
weighed 128^ pounds, having gained on an average 
almost a pound every day. He now looks the picture of 
health, has ruddy cheeks, feels strong, and is able to 
take long walks without any fatigue. 






SITOPHOBIA OF ENTERIC ORIGIN. 39 

Another case not nnlike the one just described is the 
following : 

Joseph W , 23 years old, ladies' tailor, had been 

suffering for the last two years with digestive disturb- 
ances (fulness after eating and constipation). Six 
months ago he consulted me, complaining principally of 
severe constipation. He was given tincture of rhubarb, 
but his condition did not seem to improve much. The 
appetite was not especially good and the constipation be- 
came more obstinate. He was afraid to eat much, as he 
believed the more he ate the more he would be consti- 
pated and the sooner he would have to resort to a cathar- 
tic. He ate everything, but only in small quantities. 
He was also compelled to take a glassful of whiskey in 
the morning on an empty stomach and two to three times 
during the day in order to be able to do his work. He 
gradually became weaker, and lately lost fifteen pounds. 
His weight now is 110 pounds. 

On examination, patient is found to be emaciated and 
pale. The thoracic as well as the abdominal organs do 
not reveal anything abnormal. The tongue is not coated. 
Urine contains neither aibumin nor sugar. Patellar re- 
flexes are present. 

The diagnosis of habitual constipation with sitophobia 
was made and the patient treated accordingly. 

In the two cases above detailed the sitophobia devel- 
oped as a sequel to obstinate constipation. The patients 
were afraid to tax the intestinal tract with much food, 
as it was apparently unable to dispose of even small 
quantities of the most delicate aliments. 

I have, however, seen instances in which chronic diar- 
rhoea also gave rise to sitophobia. Of the many cases I 
have observed I will report only one. 

Mrs. K. O , about 33 years old, had been com- 



40 DIET AND NUTBITION. 

plaining for the last four or five years of great flatulency 
and diarrhoea. She had four to six movements daily and 
one or two during the night — about 3 or 5 a.m. The 
dejecta were either watery or mushy, and always con- 
tained a considerable amount of mucus. Before an evac- 
uation took place there was always a great deal of rum- 
bling in the bowels, accompanied by slight colicky pains 
and passing of flatus. Her appetite was fair and there 
was no discomfort after meals. Patient, however, was 
very careful in her diet, taking principally mutton 
broth, scraped beef, and toasted bread, and of these very 
small quantities. She was afraid of aggravating her 
trouble by partaking of more food. Patient had con- 
stantly lost in flesh in the last two years, altogether about 
forty pounds. She feels weak, complains a great deal of 
dizziness, a dry sensation in her mouth, and restless 
sleep, and is unable to attend to her household duties. 

The physical examination shows that a condition of 
enteroptosis prevails. The gastric contents do not reveal 
anything abnormal. The fecal matter contains some mu- 
cus and a considerable quantity of undigested food. 

The diagnosis of enteroptosis and chronic enteritis is 
made. Patient is put on a liberal diet — salads, fruits, 
and coarse vegetables excepted — she is permitted to eat 
everything. She is also instructed to partake of kumyss, 
and bread and butter between meals. Besides the diet, 
patient is given tannigen (seven and a half grains three 
times a day). Under this regime she has steadily im- 
proved, gained considerably in weight, and her bowel 
trouble has yielded to a great extent, although it has not 
entirely disappeared. 

Remarks. — In the observations just narrated the sito- 
phobia was marked and had its origin in the belief that 
the bowel trouble might become aggravated by partaking 









SITOPHOBIA OF EXTEEIC OKIGIK 41 

of nourishment to some extent. Nor are these cases rare. 
Sitophobia of a moderate degree is almost an every -day 
occurrence in various intestinal disorders. 

Having emphasized the fact that sitophobia is met 
with in enteric affections, it does not appear superfluous 
to describe its dangers and also its treatment. 

While in conditions accompanied by diarrhoea the 
avoidance of food may for a short while exert a bene- 
ficial influence upon the intestinal affection, it is quite 
different in most cases of habitual constipation. The 
latter condition becomes the more aggravated the less 
food is taken. The constipation growing more pro- 
nounced, the patient is still more afraid to partake even 
of the small quantities of food which he has hitherto 
managed to enjoy. Thus there is a circnlus vitiosus: 
constipation causing sitophobia, which of itself aggra- 
vates the former affection. 

But even in diarrhoea, with sitophobia causing an in- 
sufficient quantity of food to be ingested, there is, after a 
short interval of apparent improvement, a relapse. The 
deficient nutrition leads ultimately to an undermining of 
the constitution. The natural resources for combating 
disease are weakened ; nervous symptoms manifest them- 
selves. Thus the diarrhoea quite soon is again as bad as 
ever. 

Moreover, sitophobia, no matter what be its cause, if 
left to itself is bound to endanger life. A person who 
habitually is taking an insufficient quantity of nourish- 
ment is slowly starving, and if there be no change in the 
mode of living, starving to death. 

It is hardly necessary to dwell upon the symptoms 
which appear in this state of subnutrition. They are a 
host and hardly need any comment: general anaemia, 
and then anaemia of the brain, dizziness, dryness in the 



42 DIET AND NUTKITION. 

throat, extreme fatigue, insomnia, etc. Occasionally I 
have met with albuminuria, which promptly disappeared 
upon improving the nutrition. 

Another important feature of sitophobia is the habit 
which the patient develops of eating minute portions. 
The condition which has led to sitophobia may have been 
remedied and thus the sitophobia as such may not exist 
any longer, still the acquired habit of eating very little 
may persist. This certainly can produce the same dan- 
gers to life as the original sitophobia. 

Treatment. — The patient must be made to eat sufficient 
quantities of food, no matter what is the underlying con- 
dition causing the sitophobia, and no matter how this is 
done. Sometimes persuasion alone is sufficient. Occa- 
sionally in very pronounced cases of subnutrition an am- 
ple diet cannot be adopted at once, but must be arranged 
gradually, accustoming the patient to more nourishment 
step by step. In some instances various medicaments 
will be helpful in carrying out this plan ; thus the bro- 
mides in nervous conditions, or codeine in x)ainful affec- 
tions. Sufficient nutrition is the foundation upon which 
to build the structure of health. The former lacking, 
no matter what treatment may be instituted, the structure 
will sooner or later collapse. If a solid foundation is 
laid by a sufficient diet, it is often quite easy to achieve 
perfect recovery, for the usual means of treatment will 
then prove successful in eradicating the primary disease. 






V. 

SITOPHOBIA AND INANITION, AND THEIE 
TEEATMENT. 1 

By his studies in aliment otherapy, which owes its in- 
troduction to his efforts, von Leyden has achieved im- 
mortal fame in medicine. The same may be said of S. 
Weir Mitchell, who at an earlier date published his well- 
known food and rest cure in the treatment of neurasthe- 
nia. Yon Noorden followed with classical monographs 
on diseases of metabolism, showing that an adequate nu- 
trition is of -the greatest importance in the treatment of 
chronic affections. Many clinicians, including myself, 
followed in the footsteps of the above authors. In 1893 
I wrote an article entitled u Dietetics in Diseases of the 
Stomach, " 2 and later another, " The Diet of Dyspeptics, " 3 
in which I emphasized that sufficient nutrition and fre- 
quently, in fact, overnutrition were essential in the cure 
of a great many invalids. 

This proposition at first sight seems so self-evident that 
a discussion of this subject would hardly be considered 
necessary. In reality, however, even physicians fre- 
quently sin against this fundamental truth of dietetics— 

1 Read before the American Gastroenterological Association, May 
14th, 1903, at Washington, D. C. The American Journal of the 
Medical Sciences, August, 1903. 

2 Medical Record, June 24th, 1893. 

3 Ibid., January 1st, 1898. 

43 



44 DIET AND NUTRITION. 

i.e., sufficient alimentation. I have, therefore, thought 
it worth while to report on this subject from an exten- 
sive clinical experience, in order to illustrate the great 
importance of dietetics and its application. 

1. By the term sitophobia we understand a condition 
in which too little food is taken on account of fear. 
This fear relates to pains or disagreeable sensations in 
the digestive apparatus arising after meals. To avoid 
these, patients prefer not to eat, or rather to eat as little 
as possible. Sitophobia is most common in chronic af- 
fections of the digestive system, accompanied by pains 
(gastralgia and enteralgia). These are usually ascribed 
by the patient to various foods, and, in order to avoid 
the pains, they exclude at first the coarser and later 
even easily digestible articles from their dietary, taking 
finally only small quantities of milk or broths. Some- 
times sitophobia arises in consequence of an abnormal 
sensibility of the gastric mucous membrane (hyperses- 
thesia ventriculi). This is but another variety of the 
cases just described; for even if in hyperesthesia of the 
stomach no severe pains are experienced, yet the inges- 
tion of food causes disagreeable sensations which the pa- 
tient is anxious to avoid. 

A further group is formed by those cases in which pa- 
tients from false ideas, in the absence of pain, avoid food 
or limit its amount. Thus especially sufferers from in- 
testinal disorders, 1 afflicted with constipation or diar- 
rhoea, are afraid to eat heartily, because they think that 
the condition would be aggravated. To 1Ms class also 
belong all cases in which the patient for some reason or 
other on account of a certain ailment eats too little in 
quantity or variety, as, for instance, gouty people avoid - 

1 " Sitophobia of Enteric Origin." Journal of the American Med- 
ical Association, June 15th, 1901. 



SITOPHOBIA AND INANITION. 45 

ing all meats, obese persons who do not take fats or car- 
bohydrates, thereby injuring the organism. 

R. von Hoesslin 1 regards sitophobia as a psychical 
condition. He says: "Such fears are not possible in 
perfectly normal people ; for the expression ' phobia ' 
presupposes the existence of an abnormal fear, based 
upon false ideas. If this fear is not abnormal, but justi- 
fiable — if, for instance, a patient suffering from acute 
enteritis is afraid to eat cabbage or prunes, or if a person 
who is always affected with urticaria after partaking of 
strawberries or lobster avoids these dishes — then we do 
not have to deal with a so-called phobia, but with a very 
sensible train of reasoning ; but if this fear is abnormal, 
some psychic change has taken place. Sitophobia is, 
therefore, like all other phobias, of cerebral origin. " 

With reference to these remarks of von Hoesslin, I 
would reply that sitophobia is certainly found in people 
who do not suffer from any psychic disturbance. The 
patients are afraid to eat because they have pain after- 
ward. This fear is justifiable; but in order to effect a 
cure it must be overcome, and, therefore, the treatment 
of this symptom (sitophobia) plays an important part. 

Sitophobia, if left alone, leads to a partial, sometimes 
nearly total, inanition. A consideration of these condi- 
tions is, therefore, not out of place here. 

2. Inanition means loss of strength owing to deficient 
nutrition. This expression was first used by Chossat 2 to 
designate the atrophy resulting from total abstinence. 
According to Samuel, 3 we must distinguish between com- 
plete and incomplete inanition. 

1 "Bemerkungen zu Dr. Max Einhorn's Artikel fiber Sitophobie 
intestinalen Ursprungs." Zeitschr. f. diatetisclie u. physikalische 
Tkerapie, 1902, Bd. v., p. 529. 

2 "Recherches experimentales sur l'inamtion," 1835. 
3 Eulenburg's "Encycl. der Med.," Bd. x., p. 320. 



46 



DIET AXD XUTKITIOX. 



Complete inanition of short duration (twelve to 
twenty-four hours) is often noted, as, for instance, in 
travellers who do not find an opportunity to obtain food 
during a voyage ; -also on fast days that are observed by 
many persons for religious reasons. 

Signs of weakness and various nervous symptoms 
(pains in the neck, severe headaches, vertigo) develop 
early and are especially marked after severe exertions. 
Prolonged periods of fasting are undergone either by 
shipwrecked people or by special professional fasters. 
The latter have been made the subject of important sci- 
entific investigations during the last twenty to thirty 
years. Our knowledge of metabolism during inanition 
is now almost complete, thanks to the labors of Zuntz 
and Lehmann, 1 Luciani, 2 and others. 

It has been shown that during complete inanition the 
organism takes up as much oxygeu as during normal rest 
— i. e. , after digestion is completed — for during the latter 
state an increased amount of oxygen is utilized, owing to 
the augmented activity of the digestive apparatus. 
During inanition the body consumes its own substance 
in order to maintain its temperature and its chief func- 
tions. It lives on its own flesh and fat and does not 
economize any more than normally. 

According to von Noorden, 3 the body during total ab- 
stinence burns up about 1 gm. of albumin and 3. 5 gm. of 
fat per day and kilo of bodily weight. 

Samuel describes the symptoms of complete inanition 
as follows: "The feeling of hunger is most intense after 
twenty hours, and disappears after that ; the feeling of 



1 "Bericlit liber die Ergebnisse des an Cetti ausgefiihrten Hunger- 
versuches." Berl. klin. Wochenschr., 1887, p. 42. 

2 "Das Hungern," 1890. 

3 Berl. Klinik, 1893, Heft 55, p. 1. 



SITOPHOBIA AND INANITION. 47 

thirst, however, remains until death. The mucous mem- 
branes become dry ; weariness, weakness, and faintness 
are pronounced. The loss of weight is continuous. The 
mental faculties remain clear until the last. Sub finem 
vitae albumin and mucin appear in the urine. The tem- 
perature sinks to 30° C. during the last twenty-four hours, 
and death occurs amid extreme prostration, deep coma, 
at times delirium and convulsions. During absolute ab- 
stinence death supervenes between the twelfth and twen- 
tieth days. If water is taken, life may be sustained for 
forty to seventy days. Forty per cent of the bodily 
weight is usually lost before death." 

Incomplete inanition or subnutrition is frequently met 
with. In relatively few cases we have to deal with con- 
ditions in which the organism is unable to utilize larger 
amounts of food (carcinoma cardiae, seu ventriculi, sen 
pylori — extreme degrees of benign stenosis of the pylo- 
rus, infectious diseases during the febrile period). In 
most cases of subnutrition, however, we have to deal 
with conditions in which the organism would be perfectly 
capable of utilizing food if it were supplied to it. These 
are, therefore, conditions in which amelioration is possi- 
ble, 

Subnutrition begins as soon as the usual amount of 
food is diminished. The daily physiological quantity of 
food is about 100 to 130 gm. of albumin, 70 to 120 gm. 
of fat, 350 to 400 gm. of carbohydrates, 2,500 to 3,000 
gm. of water, and 14 to 32 gm. of inorganic salts. Be- 
sides we inhale 744 gm. of air. The total amount of 
new material that is daily ingested is about 4 kilos, or 
about one-fifteenth of the total bodily weight. Ex- 
pressed in calories, the body needs daily for each kilo 
about 35 to 40 calories during rest and 40 to 50 during 
hard work. If less food is taken an incomplete inanition 



48 DIET AND NUTRITION. 

results, which manifests itself by anaemia and loss of 
weight. Incomplete inanition, qualitatively — as, for in- 
stance, total abstinence from water, even such as occurs in 
solid food — leads, according to Samuel, to death just as 
quickly as complete inanition. On a purely albuminous 
diet the body fat disappears, and on a diet consisting of 
fats or carbohydrates alone the bodily albumin dimin- 
ishes. A diet deficient in salts is badly borne. Diges- 
tive disturbances arise and nervous symptoms (trem- 
bling, muscular weakness) and death follow. 

In practice we meet less often with a one-sided subnu- 
trition (one deficient in a qualitative way) than with 
general subnutrition. The latter is encountered in the 
greater number of dyspeptics. I would like to cite here 
some examples from my practice as I meet them every 
week — in fact, almost daily — in order to show how much 
less food dyspeptics take than the physiologically re- 
quired quantity : 

Case I. (March 15th, 1903).— Mrs. Sadie M , aged 

38 years, complains for the last six years of pains about 
half an hour after meals, and much belching. She 
weighed formerly 168 pounds, and has decreased to 100 
pounds in five years. She feels weak, without energy, 
sleeps poorly, and has pains after meals. She fears to 
eat on account of pain. During the last four months she 
has lived as follows : 

Calories. 

8 a.m. One cup of milk (200 c.c.) 128 

One slice of stale bread (30 gm.) without butter 64 

12 m. One-quarter pound of steak 125 

One potato (25 gm ) 22 

Occasionally a half slice of stale bread 32 

5 p.m. One-eighth pound of steak 62 

Two slices of stale bread 128 

561 

The patient took daily 12^ calories per kilo weight. 



SITOPHOBIA AND INANITION. 49 

Case II. (September 24th, 1902).— Mrs. F. H , 

aged 38 years, has complained for two years of a feeling 
of constriction in the upper abdominal region. Appe- 
tite was increased, bowels were regular. During the last 
year she has lost 25 pounds (weighing originally 120 
pounds and going down to 95 pounds). 

She felt very weak, being hardly able to walk up- 
stairs. During the last year the bill of fare of the pa- 
tient was as follows: 

Calories. 

8 a.m. One chop (30 gm.) 37 

Thin slice of bread (30 gm.) 64 

Some butter (5 gm. ) 42 

One cup of coffee with very little milk (30 c.c.) 20 

10 a.m. One cup of broth (200 c.c.) 10 

12 m. Meat (100 gm.) 213 

Potatoes (50 gm.) 63 

String beans (30 gm.) , 100 

No bread. 

3 p.m. Cup of coffee with a teaspoonful of milk 3 

One slice of bread (30 gm.) 64 

7 p.m. Steak (100 gm.) 213 

One slice of bread (30 gm. ) 64 

A little butter (5 gm.) 42 

10 p.m. Claret and one cracker (10 gm.) 35 

970 

The patient was therefore taking food of a nutritive value of 22^ 
calories per kilo daily. 

Case III. (March 6th, 1903).— Lena F began to 

suffer a year ago from pains in the stomach, occurring 
one hour after meals. She was told by a physician to 
fast six days — i.e., not to take anything at all at first 
and later only a little liquid food. She did this and was 
reduced from 100 pounds to 80 pounds. Afterward she 
slowly recovered and felt quite well for several months ; 
she gained in flesh so that she weighed 104 pounds. 
4 



50 DIET AND NUTBITIOK 

About four mouths ago the patient began again to expe- 
rience pain in the stomach after meals; she ascribed this 
to various articles of food, and gradually eliminated one 
after the other from her dietary. She steadily lost in 
flesh and weighed but 89 pounds when she first consulted 
me. Her diet then was as follows : 

Calories. 

8 a.m. One slice of toast (30 gm.) 64 

One cup of milk (200 c.c.) 128 

10 a.m. One cup of beef-tea (200 c. c.) 13 

12 m. One plate of soup (200 c.c.) with rice (30 gm.) or 

barley 100 

One thin slice of bread (30 gm. ) 64 

One ounce of scraped beef 30 

3 p.m. One cup of milk (200 c.c.) 128 

Two crackers (20 gm. ) 70 

Some butter (5 gm. ) 42 

6 p.m. Beef-tea (200 c.c.) 13 

One slice of bread (30 gm.) 64 

Scraped beef (30 gm. ) 30 

One saucer of farina (100 gm.) 182 

10 p.m. One cup of malted milk (200 gm.) 128 

1,056 

As patient weighed 89 pounds, she was taking on an average a 
daily amount of 26.4 calories per kilo. 

These three cases suffice iu order to show how gravely 
the nutrition of the organism must suffer if for long pe- 
riods on an average only about two-thirds (sometimes 
even one-third) of the food necessary to maintain the 
equilibrium is taken. If we study the above figures no- 
body will be surprised that such patients steadily decline 
and complain of weakness and various nervous disturb- 
ances. What is rather to be wondered at is the fact that 
such patients linger so long in their miserable condition 
and do not succumb sooner. 






SITOPHOBIA AND INANITION. 51 

Treatment. — In complete inanition lasting twenty-four 
hours or longer, the treatment consists in carefully ad- 
ministering easily digestible fluid or semifluid food in 
not too large amounts. It is quite natural that the fam- 
ished are inclined to devour greedily any food that is ac- 
cessible. If, however, they take too much or too coarse 
food it readily causes serious trouble in the exhausted 
intestinal tract. The chief duty of the physician, there- 
fore, consists in proceeding with caution and restriction 
with regard to the taking of food during the first few 
meals. If after eating the exhaustion of the patient has 
disappeared, he may then return to his usual mode of 
life. 

The treatment of incomplete inanition or subnutrition 
is altogether different. Here we must first combat sito- 
phobia, if it exists, because otherwise the existing mal- 
nutrition can hardly be removed. It is important to en- 
courage the "patient to eat in spite of the pain. Usually 
the latter is in reality not so severe, and in nearly all 
cases we will succeed after a while in banishing the fear 
of food. Soon the patient can take ordinary nourish- 
ment. Even articles of diet which formerly caused se- 
vere pain are now tolerated without difficulty. The 
stomach, or rather the intestinal tract, seems to accustom 
itself to the greater demands made upon it. 

It is, of course, advisable in some cases at the begin- 
ning of the treatment to diminish the sensitiveness of 
the digestive apparatus by bromides or similar drugs. 
These medicines are, however, not essential, but rather 
bridge over the first few days by facilitating the carry- 
ing out of the directions in regard to eating. 

Another point of great importance is to improve the 
nutrition of the patient. At first we have to see that the 
patients take as much food as is necessary to maintain 



52 DIET AND NUTRITION. 

their equilibrium, aud that 110 loss of weight occurs. 
This alone, however, is not sufficient for a complete cure ; 
for many of these patients are very much run down, 
and, while they will not lose any more weight with an 
amount of food that is just sufficient for their needs, 
they will, however, remain in their weakened condition. 
It is, therefore, very important that an increased quan- 
tity of food should be given, in order to make the patient 
gain in weight. 

At first sight the accomplishment of this seems hardly 
possible. In reality, however, it is not so difficult, and 
can easily be done in most dyspeptic conditions (except 
carcinoma of the stomach and bowel). 

In laying out a plan of alimentation the following 
points should be considered: The first change in diet 
must not be too great. If we have to deal with patients 
who have lived for a long time on fluid food only, it is 
best to begin with liquid or semisolid food, as, for in- 
stance, milk, beef -tea, raw eggs • beaten up in milk, or 
broths, strained barley or oatmeal soups, gruels, and jel- 
lies. We must, however, see that a sufficient quantity 
of nourishment is taken. This light transitional diet 
should be increased daily by some article or other ap- 
proaching more nearly to the ordinary bill of fare. At 
first soft-boiled eggs, zwieback, tender meat, mashed 
potatoes, white bread, butter; later, light vegetables, 
boiled fruits, etc. , are added. 

As soon as the patients partake of the usual articles of 
food they should be instructed to eat about as much as 
their" neighbors at table, only taking more butter (at 
first one-eighth, later one-quarter pound daily), and 
taking a glassful of milk and a slice of buttered bread 
regularly between meals. With a diet like this we suc- 
ceed nearly always in obtaining an increase in weight. 



SITOPHOBIA AND INANITION". 53 

Thus in all the three cases mentioned above, which have 
been picked out at random from my journal, the pa- 
tients gained even in the first few weeks after beginning 
this regimen. 

The first case (Mrs. Sadie M ) gained two pouuds 

the first week; the second (Mrs. F. H ) fifteen 

pounds in five months after the beginning of the treat- 
ment; the third case (Mrs. Lena F ) gained three 

pounds in the first three weeks, and eight pounds in seven 
weeks after commencing treatment. 

The increase in weight, of course, continues as long as 
this excessive amount of food is taken. At the same 
time we find a general increase in bodily strength, so 
that patients who were invalids for a long time and a 
burden to their families and themselves could again re- 
sume their work and become useful members of society. 

Simultaneously with this strengthening of the body 
the original complaints, usually not due to organic le- 
sions, can be at the same time removed by medical, skill. 
Alimentotherapy, therefore, in these cases is the funda- 
ment of complete recovery. 



VI. 

THE ART OF INCREASING AND DIMINISHING 
THE BODILY WEIGHT AT WILL. 1 

The physician is frequently confronted with the prob- 
lem of modifying the bodily weight in one or the other 
direction. Many chronic maladies are accompanied by 
considerable loss of weight, and in their enfeebled state 
the patients are greatly hampered in their battle against 
disease. If, however, we succeed in putting them into 
a better general condition, then they are enabled vig- 
orously to combat their troubles. To obtain an increase 
in weight is therefore here of primary importance. 

An excessive bodily weight also leads to disagreeable 
conditions, occasionally even to disease. Accumulations 
of fat around the heart and intestines impede the action 
of these organs. The ponderous body is sometimes too 
heavy for the legs ; laziness results, leading occasionally 
to fatty degeneration of important muscles, including 
the heart. In all these cases a reduction of bodily weight 
must be sought. 

It does not appear superfluous, therefore, to discuss 
the question how to change the bodily weight in one or 
the other direction. 

I. The principles governing these problems are inti- 
mately connected with the physiology of metabolism and 
must first be briefly considered. 

1 Read at the annual meeting of the Monroe Count3 r Medical So- 
ciety, at Rochester, NY., May 27th, 1903. Medical Record, July 
18th, 1903. 



CHANGING BODY- WEIGHT. 55 

The Revenues and Expenditures of the Body. — In the life 
of every being there is a constant exchange of revenues 
and expenditures. The revenues of the body consist, as 
we all know, of food and air ; the expenditures, of the 
generation of bodily heat necessary for life and of the 
work performed (heart action, respiration, glandular 
activity, muscular work in general). 

The value of food is measured by its caloric energy. 
Heat may be transformed into power and the latter into 
the former. The mechanical equivalent of one calorie — 
425.5 kgm. If the work performed (expressed in kilo- 
gramme ters) is known it can be calculated according to 
the above formula in calories, i.e., we can tell exactly 
how much heat is consumed in the work accomplished. 
The human organism, however, is not able to convert 
the entire number of heat units into work. According 
to Yon Noorden, 1 the organism requires for a certain 
amount of work about four times the amount of poten- 
tial energy ; in other words, seventy-five per cent of the 
calories, changed into power, are given off in the form 
of heat which radiates from the body and is thus lost. 

A person performing about 4,000 kgm. work uses, 
therefore, |^xl = 37.6 calories. 

7 4*25.5 

The amount of food for the adult per day has been cal- 
culated at about 2, 600 calories. 

Body Equilibrium. — If the amount of food taken is just 
sufficient for all demands of the body we have a balanc- 
ing of bodily weight or bodily equilibrium, i.e., the or- 
ganism neither loses nor gains in weight. 

What Happens When More or Less Food is Taken? — 
Formerly the view prevailed that the more food is sup- 

1 C. v. Noorden: "Lehrbucli der Pathologie des Stoffweclisels," 
Berlin, 1893. 

LofC. 



56 DIET Als T D KTJTEITIOK 

plied to the animal organism the more material it burns/ 
up. As a x)roof of this theory, the fact was adduced 
that a short time after eating the consumption of oxygen 
and the elimination of carbonic acid gas were found to 
be increased. Speck * proved, however, that the in- 
creased consumption of oxygen was to be ascribed to the 
increased activity of the digestive glands, and therefore 
the theory of augmented combustion of increased nutri- 
tive material had to be abandoned. There are numerous 
proofs that the organism does not burn up food intro- 
duced in excess, but rather utilizes it and converts it into 
fat. 

On the other hand, the organism consumes just as 
much material even when no food is taken, using up its 
own substance (fat and muscles). In acute inanition the 
adult usually expends about 2, 100 calories ; in protracted 
inanition somewhat less, about 1,700 to 1,900 calories 
per day. The loss of nitrogen of a healthy fasting man 
is about 10 to 11 gm. daily. 

Work and Rest. — With increased muscular work the 
expenditure is much larger, as is evident from the above. 
Lavoisier was the first to recognize this important law. 
Zuntz 2 has distinguished himself in this field by many 
important investigations. This celebrated savant has 
determined the following values for the calories expend- 
ed in the occupations of ordinary life : 

" Walking on a level road requires between 0.5-0.6 
calories per kilogram and per 1,000 metres, according to 

1 Speck: " Experimentelle Untersuchungen liber den Einfluss der 
Nahrung auf Sauerstoffverbrauch und Ivohlensaureausscheidung." 
Arcliiv fur Experimentelle Pathologie und Pharmacie, ii., p. 412, 
1874. 

'"Zuntz: " Beraerkungen zur therapeutischen Verwertung der 
Muskelthatigkeit." Zeitschrift fur diatetische und physikalische 
Therapie, Bd. v., p. 101. 



CHANGING BODY- WEIGHT. 57 

the degree of skill in walking * of the individual. A 
man weighing 80 kgm., and travelling 75 meters per 
minute, would therefore nse for every 1,000 metres 
walked abont 80 x 0.55 = 44 calories, or 3.3 calories 
every minnte, this being about two and one-half times as 
much as during absolute rest. If there is a ten-per-cent 
grade in the road the total amount per 1,000 metres is 
44 + 60 = 104 calories, or ^|^ = 7.8 calories per 
minute, 468 calories per hour ; this is about the limit of 
what a strong man is able to perform for any length of 
time. 

"On accelerating the gait the consumption increases 
about 0.0024 calories per 1,000 metres for every metre of 
increased rapidity between 60-100 metres per minute, 
above 100 metres in increased ratio. 

" In wheeling, according to Leo Zuntz, the hourly in- 
crease of consumption over that of absolute rest for a 
man weighing 70 kgm. is as follows : 

Calories 

Going 9 km. per hour 183 

Going 15 km. per hour 313 

Going 22 km. per hour 571 

Going 9 km. per hour, three per cent grade 316 

Going 15 km. per hour, and headwind of a velocity of 10 
metres per second 601 

If, for instance, an adult should traverse four English 
miles (6,436 metres), he would consume 6,4 f * 44 = 283 
calories. 

With increased work, under the same diet, a person in 
a state of physiological equilibrium must lose in weight ; 

1 Every mechanical impediment, every tenderness in muscles, ten- 
dons, or joints, like disturbances of coordination (beginning tabes), 
increases considerably the calorie consumption in walking. 



58 DIET AND NUTKITICXN". 

the increased consumption of calories is supplied from 
the body tissue. On the other hand, under the same 
conditions (i.e., ingestion of the same amount of food), 
but with marked diminution of the usual amount of 
work (rest in bed), an increase of bodily weight must 
follow. 

Expressed in other words, this means that the body 
normally does not lose any of the food introduced (after 
deduction of the usual not utilized residue, which almost 
always represents a constant percentage), and converts 
all ingested material into energy (heat or power) or into 
tissues. In the same manner, every effort of the organ- 
ism (heat, energy) must be compensated for by calori- 
facient material, no matter whether it be furnished by 
the food or by the body itself (in case of abstinence from 
food). 

After these digressions in the realm of physiology let 
us return to our subject: 

II. An increase of bodily weight is often desirable in 
conditions of emaciation and leanness. 

Leanness is met with, although rarely, in persons who 
are perfectly healthy. These are usually individuals of 
a vivacious temperament doing a great deal of work and 
eating only moderately. Such persons are apt to remain 
lean, and may reach an advanced old age without gain- 
ing or losing. 

It is quite different Avith those frequently occurring 
cases of emaciation. The latter accompanies chronic 
diseases of various nature, and usually progresses stead- 
ily. These patients lead a miserable life, and are usually 
unable to resist any intercurrent disease, and, though 
they may live some years, hardly ever reach old age. In 
the majority of instances they fade away much earlier. 



cha;n t gixg body-weight. 59 

In emaciation, as is evident, it is imperative to coun- 
teract it — this, in fact, constituting the main object of 
treatment. But also the leanness of the healthy, if it is 
of a high degree, ought to be combated. For these per- 
sons are at a great disadvantage as compared with nor- 
mal people. They have no reserve fat on which they 
can fall back in time of need. This may be fraught 
with fatal consequence in supervening acute febrile dis- 
eases. 

Can leanness and emaciation be successfully combated \ 
This question must be answered in the affirmative. In 
nearly ninety to ninety-five per cent of all the cases of 
leanness and emaciation (cancer, of course, excepted), in 
which I have made an extended trial to raise the bodily 
weight, I have been successful. 

Increasing the Bodily Weight. — If we desire to obtain a 
rise in bodily weight, we must introduce into the body 
larger amounts of food, and especially nutriments of a 
high caloric value. Practically we proceed as follows : 
We inquire minutely how the patient has recently lived; 
what kind of food and how much he has taken with every 
meal. If we find that his diet was one-sided, we must 
immediately change it; for a diet list excluding many 
important foodstuffs is always deleterious in the long 
run. We will therefore permit as great a variety of 
food as is compatible with the condition of the case. 

We then inquire as to the quantity of food ingested. 
Should the latter be insufficient it must be our aim to 
prescribe the food in somewhat larger quantities. If the 
normal amount is taken, we must make the beverages 
taken with the meals more nutritious. Coffee and tea, 
for instance, are given diluted one -half with milk and a 
small addition of cream as well as sugar, or, instead of 
coffee, a glass of milk is ordered. 



DIET AND NUTRITION. 



Iu suitable cases two or three smaller meals, consisting 
of milk and buttered bread, may be given with advan- 
tage. 

It is advisable to prescribe the daily amount of butter 
that should be taken: I usually order a quarter of a 
pound per day. Butter is a fat easily digested, and, on 
account of its high caloric value, especially suitable. 

The success of treatment is practically assured, if it is 
possible to get the individual to take larger amounts of 
food. We often have to deal with persons whose appe- 
tite is very poor. Here, besides the usual remedies, we 
have to make use of the following dietetic means : Bread 
and vegetables, as well as milk and eggs, can usually be 
taken with relish, even if a marked antipathy for meat 
exists. The addition of olives, lettuce, horseradish, etc., 
sometimes aids in overcoming this. A glass of cold wa- 
ter stimulates the appetite while eating and induces a 
larger consumption of food. It is self-understood that 
we make use of all these measures, which besides their 
dietetic importance contribute to the patient's enjoy- 
ment of life, provided no serious contraindications are 
present, 

Outdoor life and moderate exercise (walking, light 
gymnastics, bowling, etc.) are of great value. The lat- 
ter stimulates the appetite, and by satisfying it the in- 
creased loss of heat through muscular work will not only 
be compensated, but probably an excess of food will be 
ingested without trouble. Exercise, furthermore, serves 
the purpose of stimulating muscular development and of 
strengthening the body. 

By means of a suitable combination of food and exer- 
cise, we effect not only an increased formation of adi- 
pose, but also of muscular tissue, and a gain in strength. 

III. The bodily weight should be reduced as soon as 



CHAXGING BODY-WEIGHT. 61 

there is a surplus of fat, which is displeasing to the eye 
or mars the harmouy of the body. 

There are two ways of diminishing the bodily weight : 
first, diminution of the amount of food taken ; secondly, 
increase of the amount of work performed, or a combi- 
nation of both. 

Karell, 1 and after him S. Weir Mitchell, 2 have tried 
to treat obesity by a restricted milk diet. S. Weir 
Mitchell says: "Karell has pointed out that on a cream- 
less milk diet fat people lose flesh. 

"This can be done rapidly and with safety by the fol- 
lowing means : The person whose weight we decide to 
lessen is placed on skimmed milk alone, with the usual 
precautions, or at once we give skimmed milk with the 
usual food, and in a week put aside all other diet save 
milk and all other fluids. When we find what quantity 
of milk will sustain the weight, we diminish the amount 
by degrees, "until the patient is losing a half pound of 
weight each day, or less or more, as seems to be well 
borne. Meanwhile, during the first week or two, rest in 
bed is eu joined, and later, for a varying period, rest in 
bed or on a lounge is insisted upon, while at the same 
time massage is used once or twice a day, and later in 
the case Swedish movement. At the same time the pulse 
and weight are observed with care, so that if there be too 
rapid loss or any sign of feebleness the diet may be in- 
creased. In many such cases I allowed daily a moderate 
amount of beef or chicken or oyster soup — more as a re- 
lief to the unpleasantness of a milk diet than for any 
other reason." 

Banting's cure also is based upon a reduction of the 

1 Philip Karell: "Milk in Cardiac Hypertrophy." Edinburgh 
Medical Journal, August, 1866. 

'S. Weir Mitchell: "Fat and Blood." Philadelphia, 1884. 



62 DIET AND NUTRITION. 

amount of calories introduced with the food (nearly ex- 
clusively meat diet). 

Oertel l was the first to call attention to the value of 
muscular exercise in the treatment of obesity. By a 
gradual slow increase of work it was found possible to 
accustom even a weakened heart to greater exertion. 
Oertel, as is known, recommended for this purpose the 
climbing of light grades. 

Zuntz 2 is of the same opinion, and advises in treating 
obesity to utilize muscular activity. In the treatment of 
obesity we must endeavor to free the body from super- 
fluous fat, without impairing the amount of albuminoid 
substance (muscles). This can be most easily accom- 
plished if with a moderate but sufficient diet the usual 
amount of work is slowly increased without augmenting 
the amount of food consumption. It is more difficult if 
at the same time that work is increased the amount of 
food is considerably decreased. 

Practically we should proceed as follows: We must 
determine exactly under what dietary (this must be esti- 
mated quantitatively in an approximate manner) an indi- 
vidual will remain in a state of bodily equilibrium. If 
the person has not gained lately, we may take the amount 
of food that he has been in the habit of consuming as a 
standard. If, however, he has been gaining on this 
quantity, we ought to diminish it, allowing, for instance, 
only one slice of bread instead of two or three, leaving 
off intermediate meals, etc. The weight of the patient 
should be controlled every two or three days, or weekly, 
by the scales. As soon as the amount of food nect ssary 

'Oertel: "Allgemeine Therapie der Kreislaufsstoningcn,' : Leip- 
sic, 1884 

2 Zuntz: " Zeitsclirift fur diiitetische und physikalische Therapie," 
loc. cit. 



- CHANGING BODY- WEIGHT. 63 

to keep the body in equilibrium has beeu determined, we 
must begin slowly to increase his muscular work. He 
should walk one-half to three-quarters of an hour in ad- 
dition to his usual work, or ride a wheel, or row or fence, 
or play billiards or golf, or hunt or fish. Gradually the 
time for exercise may be lengthened or the degree of 
work intensified; as, for instance, by traversing the 
same distance in shorter time, when walking, cycling, or 
rowing. This materially increases the consumption of 
calories. If we proceed slowly and carefully, we can 
soon obtain considerable work even from individuals 
that are weak. 

In increasing the work never allow the patient to be- 
come exhausted. The accelerated heart action and res- 
piration due to the exertion must return to normal ten 
minutes after beginning to rest. If this is not the case, 
the work must be reduced. 

IV. We have seen that by means of suitable diet and 
muscular work the body weight may be increased or re- 
duced at will. It is also gratifying to note that the 
increase or reduction of the body substance, if it is ad- 
vantageous for the organism, will be distributed in a 
harmonious way, so as not to offend our aesthetic feel- 
ings. In a general way, we will be right if we maintain 
that beauty and health with regard to bodily shape go 
hand-in -hand. When an increase in body-weight is ac- 
companied by increased beauty it will be found to be 
of hygienic value. In a similar manner, a decrease of 
weight bringing out a more harmonious appearance is 
certainly also advantageous to health. 

The axiom that fat and muscular tissue are evenly dis- 
tributed when an increase takes place is, however, sub- 
ject to an exception in the interest of the organism. 
The deposition of fat is somewhat greater in places 



64 DIET AND NUTBITION. 

where the subjacent muscles are not called into frequent 
play, whereas the muscles increase to the largest extent in 
such places where they are called frequently into action. 
In reducing weight the opposite holds good. The great- 
est loss in fat occurs in places where the muscles are 
most exercised, and the greatest loss in muscular tissue 
where muscular activity is small. The advantage of this 
arrangement is that fat is deposited in such places where 
it can cause the least harm, and muscles where they are 
of most value. In the disintegration of tissue, of course, 
the contrary obtains. Thus the organism watches that 
everything shall turn out to the best advantage, i.e., it 
makes use of everything (work and food) for its own 
benefit. 

It is a grateful task for the physician to intervene 
where in consequence of a false mode of life (too much 
or too little food, too much or too little work) harm may 
result to the organism. At the same time we must feel 
great satisfaction in the knowledge that through simple 
means (diet and muscular work) we are able to effect an 
improvement or a cure of the harmful conditions present. 



MAY 4 1905 



